Nursing Investigation Results -

Pennsylvania Department of Health
DONAHOE MANOR
Patient Care Inspection Results

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DONAHOE MANOR
Inspection Results For:

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DONAHOE MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on February 19, 2020, it was determined that Donahoe Manor 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(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on review of policies, clinical records and grievance reports, as well as staff interviews, it was determined that the facility failed to accommodate the residents' needs by failing to ensure that call bells were within reach while on a bed pan for one of two residents reviewed (Resident 2).

Findings include:

The facility's policy regarding bed pan use, dated January 8, 2020, indicated that after the resident was placed on the bed pan, staff were to place the call bell and toilet paper within the resident's reach and instruct the resident to ring when finished.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 15, 2019, indicated that the resident was cognitively intact; required extensive assistance with bed mobility, transfers and toileting; and had a history of falls. The resident's care plan, dated November 8, 2019, revealed that staff were to assist the resident with toileting, reinforce the need to call for assistance, and to have commonly used articles within easy reach.

A grievance report, dated January 10, 2020, revealed that Resident 2 stated that she was left on a small bed pan for over an hour. She was unable to call for help because her door was shut and her call bell was not in reach. The facility's investigation documents, dated January 10, 2020, revealed that the resident had no ill effects and was removed from the bed pan, and the call bell was placed within her reach.

Interview with the Director of Nursing on February 18, 2020, at 8:25 p.m. confirmed that Residents 2's call bell was placed out of her reach while she was on the bed pan.

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







 Plan of Correction - To be completed: 03/17/2020

1. Resident 2 assessed at time of incident and had no ill effects related call bell not being in reach while on bed pan. Care provided to resident at time of concern.
2. All current and new residents have the potential to be effected by this deficient practice. A full house audit to be completed on placement of call bells/call bells within reach by Director of Nursing/designee utilizing the Quality Assurance Performance Improvement Nursing Services Audit Tool. Daily rounds are completed on each shift to ensure call bells are in resident reach. Audits are reviewed at morning meeting
3. Director of Nursing or designee will educate current and new staff, including agency, regarding facility Call Bell policy, with emphasis on maintaining call bells within resident reach.
4. Director of Nursing/designee will randomly audit call bell placement utilizing the Quality Assurance Performance Improvement (QAPI) Nursing Services Audit Tool weekly x4 weeks; monthly x2 months to ensure compliance. Audit results will be discussed by the QAPI Committee who will provide appropriate follow up.





483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed ensure that staff followed the facility's policies regarding investigating allegations of possible resident abuse/mistreatment in a timely manner, and failed to protect the resident/victim for one of two residents reviewed (Resident 1).

Findings include:

The facility's policy regarding resident abuse/neglect/mistreatment, dated January 8, 2020, indicated that employees were educated upon hire and annually regarding the abuse prevention program, including the immediate reporting of any suspicion of abuse, neglect, exploitation, mistreatment, misappropriation, or crime involving a resident. The administrator was responsible for investigating, reporting and coordinating the investigation process for any alleged or suspected abuse, regardless of the source of the concern. Once reported, the facility was to conduct a timely, thorough and objective investigation of any allegations of abuse. Any allegation of abuse was to be immediately reported to the supervisor and abuse prevention coordinator. Resident protective actions included immediately removing the resident from contact with the alleged abuser during the investigation. If the incident involved a facility employee, the employee was to be suspended immediately, after obtaining a statement, pending completion of the investigation. If the alleged abuser was not an employee, measures were to be taken to provide a safe, secure environment for the resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 11, 2019, indicated that the resident was cognitively intact and required limited assistance from staff for daily care tasks. The resident's care plan, dated January 22, 2020, revealed that she was non-verbal and had difficulty communicating.

A nursing note for Resident 1, dated February 5, 2020, at 5:34 p.m. and completed by Licensed Practical Nurse 1, revealed that the nurse walked into the resident's room to give a 5:00 p.m. tube feeding and breathing treatment. The resident was reading letters on her lap, she folded them and put them away, the nurse measured out the resident's tube feeding into measured cups, and then got water in another cup to thin down the tube feeding. The resident proceeded to throw the cup with the tube feeding in the garbage can and threw the cup with the water on the nurse. The resident motioned for the breathing treatment to be turned on, which was done, then the resident motioned the nurse out of the room.

Facility investigation documents dated February 13, 2020, at 5:00 p.m. revealed that Resident 1 alleged that she and Licensed Practical Nurse 1 had a disagreement the previous week. The resident indicated that she needed her breathing treatment before she received her tube feeding and medications, but Licensed Practical Nurse 1 attempted to set up the tube feeding first, and as she set the cups of tube feeding and water on the bedside table, the resident threw them away. Both the resident and Licensed Practical Nurse 1 became agitated, and Licensed Practical Nurse 1 allegedly gave the resident the middle finger and told her, "I heard you were leaving soon. I wish you the worst."

A witness statement completed by Unit Manager 2, dated February 13, 2020, revealed that an incident occurred between Resident 1 and Licensed Practical Nurse 1 on February 5, 2020. Licensed Practical Nurse 1 said that the resident threw away her tube feeding and threw water on her (Licensed Practical Nurse 1). Registered Nurse 3 said she was going to follow up with the resident, and if there was an issue between the resident and Licensed Practical Nurse 1 she would inform the Director of Nursing.

A witness statement completed by Registered Nurse 4, dated February 13, 2020, revealed that she was aware that an incident occurred between Resident 1 and Licensed Practical Nurse 1 on February 5, 2020. Registered Nurse 3 made her aware of the incident and indicated that she contacted the Director of Nursing on Wednesday, February 5, 2020, so she felt that the incident was taken care of.

A witness statement completed by Registered Nurse 5, dated February 13, 2020, revealed that an incident occurred between Resident 1 and Licensed Practical Nurse 1 on February 5, 2020. During report on Friday morning, February 7, 2020, it was reported that Licensed Practical Nurse 1 gave the resident the finger and told the resident, "I heard you were leaving. I wish you the worst." This was the original message that the resident wrote on her white board (used by Resident 1 for written communication) for Registered Nurse 3. The resident asked Registered Nurse 5 what nurse was following her because she wanted to know if Licensed Practical Nurse 1 was going to be in her section and the resident did not want Licensed Practical Nurse 1 in her room. She did not recall the resident's exact wording, but the resident summarized the event and expressed that she was fearful of Licensed Practical Nurse 1 being in her room.

There was no documented evidence that an investigation into Resident 1's allegation was started until February 13, 2020, and no documented evidence that a witness statement was obtained from Registered Nurse 3 until February 18, 2020.

Review of the facility's staff deployment sheets for February 6 and 10, 2020, revealed that Licensed Practical Nurse 1 was assigned to the area where Resident 1 resided, and Resident 1's Medication Administration Record (MAR) revealed that Licensed Practical Nurse 1 made entries on February 6 and 10, 2020, indicating that she was assigned to administer medications to the resident on those days.

There was no documented evidence that Resident 1 was protected in accordance with the facility's policy by reassigning and/or immediately suspending Licensed Practical Nurse 1 after the allegation was made by Resident 1 on February 5, 2020.

A witness statement completed by Registered Nurse 3, dated February 18, 2020, revealed that Resident 1 made her aware that she needed her evening tube feeding because she and Licensed Practical Nurse 1 argued, and the resident pointed to the garbage can where she had thrown her feeding away. Registered Nurse 3 asked the resident what was wrong and what happened, and the resident wrote on her board that Licensed Practical Nurse 1 gave her the finger, wished her the worst, and said she was glad she (Resident 1) was leaving. Registered Nurse 3 made sure the resident was taken care of and settled down, gave her medications and tube feeding, and reported the resident's information to management.

An interview with Registered Nurse 3 on February 19, 2020, at 2:06 p.m. revealed that the incident between Resident 1 and Licensed Practical Nurse 1 occurred on Wednesday, February 5, 2020. She went into Resident 1's room and the resident pointed toward the garbage can and wrote that she needed her tube feeding. The nurse asked the resident what happened and the resident wrote that she wanted Licensed Practical Nurse 1 to suction her before starting her tube feeding, and Licensed Practical Nurse 1 would not suction her. The resident then wrote that Licensed Practical Nurse 1 told her that she heard that she was leaving and she wished her the worst, then Licensed Practical Nurse 1 gave the resident "the finger." She indicated that she advised the resident that she would take care of it. She took the white board that the resident had written on and showed her supervisor (Registered Nurse 4). Registered Nurse 4 was orienting, so Registered Nurse 3 told her that she would call the Director of Nursing to inform her about the event. Registered Nurse 3 called the Director of Nursing prior to starting her evening medication pass on February 5, 2020.

Interview with the Director of Nursing on February 18, 2020, at 6:10 p.m. revealed that there was hearsay that there was a problem between Resident 1 and Licensed Practical Nurse 1, so when they did rounds on Monday (February 10, 2020), she asked Resident 1 if she had any problems with Licensed Practical Nurse 1, and the resident indicated that she could not recall any problems. Then this past Thursday (February 13, 2020) Registered Nurse 5 (a supervisor working that night) showed the Director of Nursing a picture that she took of Resident 1's communication board indicating that Licensed Practical Nurse 1 told the resident that she heard she was leaving soon and wished her the worst, then gave the resident the middle finger. Licensed Practical Nurse 1 was suspended on February 13, 2020, and an investigation was started that day.

Interview with the Director of Nursing on February 18, 2020, at 8:25 p.m. confirmed that she did not obtain a witness statement from Registered Nurse 3 regarding the incident between Resident 1 and Licensed Practical Nurse 1 until February 18, 2020, and that following the incident, Licensed Practical Nurse 1 was assigned to work the area where the resident resided.

A interview with the Nursing Home Administrator on February 19, 2020, revealed that on February 10, 2020, the Director of Nursing made her aware of the incident between Resident 1 and Licensed Practical Nurse 1. She attempted to go talk with the resident on February 11, 2020; however, she was sleeping and she was unable to speak with the resident. She attempted to speak with the resident again on February 13, 2020; however, the resident was out of the facility. Registered Nurse 5 spoke with the facility's regional nurse and asked what was being done and that is when it was determined that there was an allegation of abuse, so an investigation was started.

28 Pa. Code 201.14(a) Responsibility of licensee.

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




 Plan of Correction - To be completed: 03/17/2020

1.Resident 1's allegation was investigated and unsubstantiated by facility, Adult Protective Services and Pennsylvania State Police.
2. All current and new residents have the potential to be affected by this deficient practice. Utilizing the Quality Assurance Performance Improvement (QAPI) tool Investigation audit, concern forms and incident reports for the last 30 days will be audited by Director of Nursing/designee. Review of progress notes, incident reports and concern forms reviewed with Interdisciplinary team during morning meeting. Any concerns related to possible abuse are reviewed and investigation initiated.
3. Administrator and Director of Nursing to be re-educated by Director of Operations regarding company investigation policy. All current and new staff, including agency staff, were educated on the abuse policy on February 26, 2020 by Director of Nursing and Nursing Home Administrator regarding company investigation policy.
4. Utilizing the QAPI tool Investigation audit, Nursing Home Administrator/designee will randomly audit 3 concern forms and incident reports received for proper completion of thorough investigation according to company policy weekly x 4 weeks and monthly x 2 months, results to be submitted to the facility Quality Assurance Performance Improvement Committee to provide follow up as appropriate.

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