Nursing Investigation Results -

Pennsylvania Department of Health
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  170 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.
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on September 30, 2019, it was determined that Mountain Laurel Nursing 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:


483.21(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, observations, and staff interviews, it was determined that the facility failed to implement care-planned interventions for dining for one of seven residents reviewed (Resident 1).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 13, 2019, indicated that the resident had moderately impaired cognition, required extensive assistance with daily care activities, including eating, and had diagnoses that included dementia (loss of cognitive function). The resident's care plan, dated May 3, 2019, indicated that the resident was to have one bowl, one utensil, and one drink at a time for all meals.

A nutrition note for Resident 1, dated May 3, 2019, revealed that the resident had a weight loss of 9 percent in 3 months and an 11.5 percent loss in 5 months, and the resident's weight was stable for one month. The resident was able to feed himself with one individual bowl and one utensil at a time. A nutrition note, dated July 19, 2019, revealed that the resident was able to feed himself using individual bowls, and at other times staff assisted with meals.

Observations on September 30, 2019, at 6:50 p.m. revealed that Nurse Aide 2 provided Resident 1 his meal tray and he was given a bowl of beans, a bowl of fruit, a hot dog, a carton of chocolate milk, a cup of iced tea, a styrofoam cup of water with a straw, and a fork, knife, and spoon. The dietary slip only indicated that his food was to be in individual bowls.

Interview with Registered Nurse 1 on September 30, 2019, at 7:09 p.m. confirmed that Resident 1 should have been given only one bowl, one utensil, and one drink at a time, as care planned.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.
Previously cited 6/13/19.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 6/13/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/13/19.



 Plan of Correction - To be completed: 11/04/2019

1.The Certified Nursing Assistant received education to follow cardex(information that the care nurses use to direct their care). A new evaluation completed for self-feeding abilities.
2.A review of all residents with meal adaptive equipment will be completed to assure recommendations are reflected on the cardex and care-plan.
3. Whole house education to be completed on following cardex. New employees and Agency staff will be included in this education.
4.The designee will audit all new meal adaptive equipment recommendations to assure cardex and care plan are reflected. Audits will be completed weekly times 4 and them monthly x 2.
.Will review at Quality Assurance Performance Improvement, monthly.

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 and incident/accident investigations, as well as staff interviews, it was determined that the facility failed to ensure that interventions to prevent falls and/or injury were followed for one of seven residents reviewed (Resident 3).

Findings include:

A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 24, 2019, revealed that the resident was understood and could understand, and required extensive assistance from staff for bed mobility and transfers. The resident's care plan, dated August 26, 2019, indicated that the resident was at risk of falls and his bed was to be maintained in the lowest position.

A nursing note for Resident 3, dated September 19, 2019, revealed that the resident fell. A nurse aide reported that the resident was being seen by therapy and the bed was left in the highest position. The resident denied pain related to the fall.

An incident report for Resident 3, dated September 19, 2019, revealed that the resident's bed was left in the highest position after being seen by therapy staff. The resident was found on the fall mat on the left side of the bed. Witness statements were obtained from staff assigned to the unit that the resident was on; however, there was no documented evidence that a statement was obtained from the therapist who was working with the resident prior to the incident, to determine if he/she was aware of care-planned interventions that were to be in place for the resident.

An interview with the Nursing Home Administrator on September 30, 2019, at 8:40 p.m. confirmed that as of September 30, 2019, there was no statement obtained from the therapist who was working with Resident 3 on the day of the incident. She confirmed that the incident investigation revealed that the therapist left Resident 3's bed high in the air when it should have been put down low to the ground.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 6/13/19.

28 Pa. Code 211.10(d) Resident care policies.
Previously cited 6/13/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/13/19.



 Plan of Correction - To be completed: 11/04/2019

1.The Therapist indicated, received education on following the cardex(The cardex is the information that the care nurse uses to follow the residents care plan). The therapy department also received education on this process.
2.A whole house audit of residents whom are recommended to have a low bed will be completed and to ensure that it is reflected on the cardex and the care-plan. New employees and agency staff will also receive education.
3.Education will be provided to all nursing staff to review cardex to ensure appropriate care of the resident.New employees and agency staff will receive this education )
4.The designee will audit all new low bed recommendations to ensure they are reflected on the cardex and the care-plan. Audits will be completed weekly times 4 and them monthly x 2.
Will review monthly at Quality Assurance Performance Improvement.

483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident: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.
483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that nutritional supplements were provided timely for one of seven residents reviewed (Resident 2).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2019, revealed that the resident was cognitively impaired, at risk for pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure), and had a current venous ulcer (wound resulting from impaired circulation). The resident's diagnosis record, dated July 22, 2019, included severe protein-calorie malnutrition.

A nutrition note for Resident 2, dated July 26, 2019, indicated that the resident had severe protein depletion of his protein stores. A note dated August 3, 2019, indicated that the resident had a weight loss of 5.4 percent since admission to the facility on July 19, 2019, with a current weight of 105 pounds. It was recommended that the resident's Ensure supplements be changed to Healthshakes so he would have better acceptance of his supplements.

Physician's orders for Resident 2, dated August 3, 2019, included that Healthshakes were to be provided four times a day to aid in weight gain. There was no documented evidence that the Healthshakes were provided to the resident until August 5, 2019 (two days later).

Interview with the Director of Nursing on September 30, 2019, at 7:30 p.m. indicated that she was not aware why the Healthshakes were not provided timely and that they should have been provided on the day they were ordered.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 6/13/19.


 Plan of Correction - To be completed: 11/04/2019

1.The Resident was discharged on 9/18.
2.We will educate the Nursing staff to check the ques in Point Click Care every shift to ensure that the recommendation's are confirmed. New employees and agency staff will be included in the education.
3.Five times a week during the facility Morning meeting , the nurses will check the que in Point Click Care(electronic medical record platform) to assure that the recommendations have pulled to the Medication Administration Record appropriately.
We will also observe 3 times per week the administration of the nutritional supplements. (The LPN is responsible to sign off that it was given)
4.The designee will audit recommendations weekly times 4 and then monthly times 2.
We will review at Quality Assurance Performance Improvement monthly.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port