Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on the findings of an abbreviated survey in response to a complaint completed on February 3, 2020, at Spring Creek Rehabilitation and Nursing Center it was determined that the facility 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:

483.10(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

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).

Based on a review of clinical records, wound team reports and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant deterioration of a wound for one of 3 Residents sampled (Resident 3).

Findings included:

Review of the facility policy titled; Change in a Resident's Condition or Status, revealed a policy statement that included, our facility shall promptly notify the resident, his or her attending Physician, and POA(representative) of changes in the resident's medical/mental condition and/or status. Further review of this policy revealed a "significant change" of condition is a decline in the resident's status that; A) will not normally resolve itself without without intervention by staff or by implementing standard disease-related clinical interventions. B) Impacts more than one area of the resident's health status.

A review of the admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) completed on October 31, 2019, revealed that Resident 3 was moderately impaired cognitivily.

A review of the clinical record revealed that Resident 3, was admitted to the facility on October 24, 2019, Chronic Respiratory Failure (a condition in which not enough oxygen passes from the lungs into the blood and/or the lungs cannot properly remove carbon dioxide (a waste gas) from the blood), and Schizoaffective Disorder-(a mental disorder in which a person experiences a combination of schizophrenia symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania).

A progress note dated October 24, 2019 revealed an initial skin assessment of the resident that assessment noted an open area to the coccyx, thought to be a stage 3. A communication was placed with the wound team to evaluate the resident's wound, at that time. The wound team evaluated the resident on October 28, 2019, the open area on the coccyx(sacrum) is documented as a Stage 4 not a Stage 3, by the wound team. The area was noted to be 2 cm long x1cm wide, with an unmeasurable depth before the area was mechanically debrided (removing dead tissue with a scalpel, or other sharp instrument to uncover healthy tissue, which aids healing).

Review of the wound team weekly notes revealed Resident 3's open area on his sacrum remained relatively unchanged in surface area, however the physician documented the wound had deepened during the treatments. The deepening of the wound and the need for debridement had resulted in 10 % of the wound area being exposed bone. The surface area had remained between 3 cm2 and 4 cm2. A progress note in the resident's clinical record dated December 16, 2019, revealed " sacral pressure wound (2x2x3) treated as per doctor's orders and tolerated well. No signs or symptoms of infection noted." On December 23, 2019, a different Physician saw Resident 3 and documented the sacral wound to be 7 cm x 8 cm x 3 cm with a surface area of 56 cm2. On December 30, 2019, yet another Physician saw Resident 3 for the wound team. This physician also documented the sacral wound as being 7 cm x 8 cm x3 cm, with a surface area of 56 cm2.

However, further review of Resident 3's progress notes and wound team documentation revealed that the resident's responsible party was not notified of the resident's dramatically increased wound size, after either assessment.

Resident 3 was transferred out of the facility on December 30, 2019. There was a progress note dated that day, documenting the POA was notified of Resident 2's transfer, no documentation of the deteriorating wound was noted.

Interview with the Director of Nursing on February 3, 2020, at approximately 3:45 PM confirmed that her expectation was the facility should have contacted the resident's responsible party timely, regarding the resident's increased wound size.

28 Pa. Code 211.12 (a)(c) Nursing services.
Previously cited 11/20/18

28 Pa. Code 201.29(a) Resident rights.
Previously cited 11/20/18

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

1. Resident #3 was discharged from the facility. No adverse effects noted.
2. All new or worsening wounds for the last week will be checked to ensure that the family was notified.
3. The wound team will be educated on notifying families in a timely manner of new or worsening wounds. DON/or designee will audit all new or worsening wounds weekly x4 then 5 new wounds monthly x2.
4. Audits will be reviewed at the monthly QAPI meetings to ensure compliance for quality improvement.
5. Date of compliance is

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