Nursing Investigation Results -

Pennsylvania Department of Health
SHIPPENSBURG HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHIPPENSBURG HEALTH CARE CENTER
Inspection Results For:
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SHIPPENSBURG HEALTH CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey completed on February 13, 2020, in response to a complaint, it was determined that Shippensburg Health Care Center 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 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, select facility policy, facility investigation reports and staff interviews, it was determined that the facility failed to implement interventions to reduce hazards and risks to prevent falls for one of six residents reviewed. (Resident 1).

Findings include:

Review of the clinical record for Resident 1 revealed diagnoses including End Stage Renal Disease (ESRD-decreased ability of the kidneys to produce urine and filter toxins from the body)) and repeated falls. Resident 1 was noted on the most recent MDS (Minimum Data Set- periodic assessment of resident care and service needs) to be cognitively intact, recording a 15 out of a possible 15 on her assessment of December 5, 2019.

Resident 1 has had multiple admissions to this facility, the last previous to the incident was December 17, 2019. A quarterly fall risk evaluation was completed for Resident 1 on December 5, 2019. The evaluation revealed Resident 1 to be a Moderate fall risk at that time.

Resident 1 had a fall on January 5, 2020, at approximately 11:00 AM. Review of the fall report revealed statements from the staff member filling out the report, that the resident was "noncompliant with transfers."

An interview with Resident 1 on January 16, 2020, revealed her statement, " I transfer myself all the time."

The facility identified that the resident is non-compliant with asking for help to transfer to her wheelchair.

Review of the individualized plan of care for this resident revealed an intervention from March of 2019, (10 months previous) " intervention for the fall on 3/3/19 is staff education r/t transfers." The last new intervention for this focused care area was in September 2019. The facility did not implement interventions to reduce hazards and risks, by alerting staff that the resident was transferring herself into her wheelchair.

During an interview with the Director of Nursing on January 16, 2020, at 10:07 AM, she revealed that the interventions could have been updated.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

28 Pa. Code: 211.10(d) Resident care policies.

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

Plan of Correction - To be completed: 03/16/2020

Resident 1 care plan was reviewed and individualized based on interventions related to updating staff or resident non-compliance regarding transferring of self. Resident and family were educated on risk factors related to non-compliance with transfer status.

All residents will be assessed at time of admissions/readmission and quarterly in accordance with the MDS schedule and/or with significant change to ensure care plan reflects individualized care required by the resident.

All licensed staff will be in-serviced and educated on reviewing/updating plan of care related to falls and implementing interventions to reduce hazards.

Director of Nursing and/or designee will review residents fall assessments to ensure care plan identifies potential risk factors.

Director of Nursing and/or designee will audit all new admission/readmissions weekly for 3 months and report findings to Quality Assurance Committee.

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 clinical record reviews and staff interview, it was determined that the facility failed to maintain clinical records which are complete and accurate for one of six Resident records reviewed (Residents 2).

Findings include:

Review of Resident 2's clinical record revealed diagnoses which included, Chronic Kidney Disease (CKD- is a condition characterized by a gradual loss of kidney function over time), and generalized muscle weakness.

Review of Resident 2's clinical record revealed Resident 2 had a fall on December 24, 2019. Further review of the facility supplied documentation related to this fall revealed a form titled: Neurological Evaluation Flow Sheet. Part of this form revealed neurological checks are to be completed (after a fall) every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every 1 hour for 2 hours, then once per 8 hour shift for 72 hours. Review of this form for the fall that occurred on December 24, 2019 revealed an initial assessment at 7:35 AM, the assessments continued per policy until 10:35 AM, the next assessment was due at 11:35 AM (beginning every 1 hour assessments) however, an additional 30 minute assessment was completed at 11:05 AM. The assessments continued to be out of policy until the form was filled in. This additional assessment resulted in only seven every shift (56 hours) assessments being completed not 9 shifts (72 hours) as described on the form.

During an interview with the Director of Nursing on January 16, 2020 at approximately 10:07 AM, she revealed that there was no documentation of additional assessments having been completed. At that time, she also revealed it is her expectation the documentation should be correct and complete.

28 Pa. Code 211.5(f) Clinical records.

Plan of Correction - To be completed: 03/16/2020

Resident 2 was assessed by the Registered Nurse with no negative outcome.

The facility reviewed and revised the policy from related to neurological assessments to ensure all neuros are completed as ordered by the physician.

All licensed staff will be in-serviced and educated on the policy and new form related to neurological assessments. Nursing staff will review daily any resident on neuro checks to ensure compliance and documentation is completed.

The Director of Nursing and/or designee will randomly audit neuro assessment sheets for complete documentation weekly for 3 months and report findings to Quality Assurance Committee.

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