Pennsylvania Department of Health
GARDENS AT STEVENS, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT STEVENS, THE
Inspection Results For:

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GARDENS AT STEVENS, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to two Complaints completed on April 3, 2024, it was determined that Gardens at Stevens 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 as they relate to the Health portion of the survey process.






 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 upon clinical record and facility documentation review, it was determined the facility failed to ensure adequate supervision of a resident to prevent resident from falling from a facility window resulting in physical harm and hospitalization for Resident 1.

Findings include:

Review of Resident 1's diagnosis list revealed diagnoses including left side Hemiplegia (paralysis or weakness to one side of the body), difficulty in walking, Vascular Dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability), muscle weakness, Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real.[3] Symptoms may include delusions and hallucinations), Alcohol abuse with Alcohol induced sleep disorder, and Alcohol Dependence with Alcohol-induced persisting Dementia.

Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated February 2, 2024, revealed Resident 1 had a Brief Interview for Mental Status Score of 5 indicating severe cognitive impairment.

Review of Resident 1's Elopement Risk Assessment dated March 29, 2024, revealed Resident 1 was a moderate wander risk.

Review of Resident 1's Fall Risk Assessment/Evaluation dated March 26, 2024, revealed Resident 1 was a high risk for falls.

Review of Resident R 1's care plan initiated on Sepember 26, 2022 revealed a focus goal of [Resident] has adjustment issues to admission distractibility r/t (related/to) cognitive deficits, feelings of loss of independence/phsysical decline. Further review of same care plan revealed interventions of a "Consult with [community provider] to monitor medications," "Encourage [Resident 1] to participate in conversation with staff and other residents daily," "Encourage ongoing family involvement," and "Help [Resident 1] to identify stressors which may be early warning signs of problem behavior. Intervene and remove stressors as possible."

Further review of Resident 1's care plan revealed a care plan related to risk of falls and notation of recent falls occurring on March 1, 2023; March 25, 2023; May 25, 2023; November 14, 2023 and March 26, 2024 during which resident was identified as self ambulating. Interventions included but not limited to "Anticipate and meet [Resident 1]'s needs," "Assist of 1 for transfers and ambulation with RW (rolling walker)."

Review of Resident 1's care plan revealed a focus goal initiated November 22, 2022 for "Elopement and associated injury related to exit seeking behavior." Further review of same care plan revealed interventions including; "Assist in orientation to room and facility using verbal cues and reminders," "Encourage group activity and attempt to keep occupied," "Notify social services for persistent attempts to leave building and not responding to redirection," "provide diversional activities when exit seeking," and "wanderguard function checked each night shift and placement checked each shift."

Review of Resident 1's clinical record including progress notes dated April 2, 2024, revealed "CNA [certified nurse aide] for night shift entered unit at 2211 [10:11 p.m.] stating to other RN [registered nurse] supervisor that she saw a man outside the kitchen a minute before. This RN followed other RN down hall to check on situation. Exiting back kitchen door we observed [Resident 1] standing and leaning against stair wall. Resident noted he fell but could not determine how he got outside. Another staff member found resident glasses on ground around the other side of the building next to air conditioner units. No alarms had gone off in building. Staff had last seen [Resident 1] at 2155 [9:55 p.m.] in hallway in wheelchair. Wheelchair was not with resident when he was observed outside. Resident taken inside and placed in wheelchair. This RN assessed resident for injuries and notified [director of nursing, nursing home administrator and on call provider]. Resident with multiple abrasions to head, ankles, and knees. Decision to send to ED [emergency department] for evaluation since resident stated he fell and it was unwitnessed. Call placed to EMS. Resident's son notified of situation and ongoing investigation of events. Staff continued to search for resident's wheelchair which was found in 2nd floor restorative dining room where a window was noted to be open. EMS arrived with [police officer]. Resident transported to [acute care facility]. Resident left facility vital signs stable though not within residents normal limits, resident awake though more hypoactive, verbalized no complaints of pain however resident appeared pale and facial expressions and body language indicative of pain, injuries as noted above."

Review of Resident 1's emergency room record dated April 2, 2024, revealed "patient admitted following a fall out of window at [facility], Patient found to have two left facial fractures, left 3-6 rib fractures, left pneumothorax [air leakage between lungs and chest wall] and subarachnoid hemorrhage [type of brain bleed]."

Further review of Resident 1's acute care facility records indicate the following injuries as of April 2, 2024: traumatic fracture of ribs of left side with pneumothorax required chest tube insertion; left zygomatic arch [portion of jaw/mandible] fracture; left orbital wall [bone around eye] fracture; left maxillary [portion of jaw] fracture and left third through six rib fractures.

Review of facility documentation and witness statements dated April 1, 2024, revealed Resident 1 was observed at 9:30 p.m. near the nurses' station and last observed at 9:55 p.m. near or in resident's room in a wheelchair.

Resident 1 was next observed at approximately 10:11 p.m. outside the building near a set of stairs leading to the kitchen entrance.

Observation of the activity room windows on April 3, 2024, at approximately 9:30 a.m. revealed all windows in the activity room to have two window stop brackets on each window.

Further observation of the window on the left side of the activity room revealed two window stop brackets secured in the upper portion of the window.

Interview with the Nursing Home Administrator on April 3, 2024, at 11:00 a.m. revealed Resident 1's wheelchair was found approximately four feet from the window on the left side of the activity room on the night of the fall and the window was observed to be open at that time.

Further interview with the Nursing Home Administrator revealed no staff members were present in the activity room at the time Resident 1 opened the window or in the hours preceding the fall.

The facility failed to provide adequate supervision by facility staff to prevent accidents to a resident noted to be a High fall risk and moderate elopement risk resulting in harm and hospitalization to Resident 1.

28 Pa. Code 201.18(a)(b)(1) Management
Previously cited 3/10/2022, 3/15/2023, 10/5/2023, 2/1/2024

28 Pa. Code 211.12(a)(d)(4)(5) Nursing Services
Previously cited 3/10/22, 3/15/2023, 5/13/2023, 8/8/2023, 2/1/2024




 Plan of Correction - To be completed: 04/19/2024

1. Resident R1 has discharged from the facility on 4/9/2024.

2. Current residents noted to be a high fall risk and moderate or greater elopement risk will have care plans reviewed and updated to provide necessary supervision.

3. DON or designed will educate staff as to providing supervision to prevent resident accidents.

4. The Director of Nursing or designee will audit new residents to determine if they are a high fall risk and moderate or greater elopement risk. Residents with these indicators will be care planned for increased supervision. This audit will be weekly for 4 weeks and then monthly for 2 months. The results of the Director of Nursing's audit will be reviewed monthly at the facility's Quality Assurance and Performance Improvement meeting.

5. Facility Date of Compliance will be 04/19/2024

211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of facility staffing data and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on both day and evening shifts and ratio of one nurse aide to 20 residents on overnight shift, for the week March 25, 2024 through April 1, 2024.

Findings include:

Review of the week of March 25, 2024, revealed the following date on day shift did not meet the requirement of one nurse aide per 12 residents:

March 27, 2024 - nurse aide ratio not met on the 7-3 shift.

March 30, 2024 - nurse aide ratio not met on 7-3 shift and on the evening shift of 3-11p.m.

March 31, 2024 - nurse aide ratio not met on 7-3 shift and 3-11 shift

April 1, 2024 - nurse aide ratio not met on 3-11 shift.

Review of the week of March 25, 2024, revealed the following date on overnight shift did not meet the requirement of one nurse aide per 20 residents:

March 29, 2024 - nurse aide ratio of one to 20 residents was not met on 11-7 shift. Facility PPD was calculated to be 2.85.

March 30, 2024 - nurse aide ratio not met for one aide to 20 residents on the overnight shift of 11 p.m. -7 a.m. Facility PPD for the day was calculated to be 2.57.

March 31, 2024 - nurse aide ratio not met on the 11p.m. -7 a.m. shift. The facility staff to resident ratio (PPD) was calculated to be - 2.17.

Interview with Nursing Home Administrator on April 3, at approximately 11:00 when staffing concerns were discussed. Further interview with Assistant Director of Nursing on April 15, 2024 at approximately 3:55 p.m with the above information discussed.



 Plan of Correction - To be completed: 04/19/2024

1. Facility cannot retroactively go back and correct past CNA to patient ratios.

2. The facility did not find any negative resident outcomes associated with staffing deficiency.

3. NHA educated DON and Scheduler on staffing ratios as of July 1st. Facility implemented process of daily scheduling meeting to ensure nursing hour coverage meets new regulation. Facility continues to hire for open CNA positions.

4. NHA will audit nursing CNA ratios daily to ensure nursing coverage meets new regulations. Findings of Audits will be submitted to QAPI for review.

5. Facility Date of Compliance will be 04/19/2024.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of facility staffing data and interview with staff, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents on day shift, per 30 residents on evening shift and for 40 residents on night shift.

Findings include:

Review of the week of March 25, 2024, revealed the following dates on day shift did not meet the requirement of one LPN per 25 residents for dayshift(7 a.m. to 3 p.m.); per 30 residents on the 3 p.m. to 11 p.m. shift; or per 40 residents on the night shift of 11 p.m. to 7 a.m. shift.

March 27, 2024 - LPN ratio not met on 3-11 shift.

March 28, 2024 - LPN ratios not met on 7-3 and 3-11 shifts;

March 29, 2024 - LPN ratios not met on 7-3 shift and were not met on the 3-11 shift.

March 30, 2024 - LPN ratio not met on both 3-11 and 11 p.m. - 7 a.m. shift.

March 31, 2024 - LPN ratio not met on 7-3 shift and 3-11 shift.

April 1, 2024 - LPN ratio not met on 7-3 shift, 3-11 shift and the LPN ratio was not met on the 11-7 shift.

Interview with Nursing Home Administrator on April 3, at approximately 11:00 when staffing concerns were discussed. Further interview with Assistant Director of Nursing on April 15, 2024 at approximately 3:55 p.m. with the above information discussed.


 Plan of Correction - To be completed: 04/19/2024

1. Facility cannot retroactively go back and correct past LPN to patient ratios.

2. The facility did not find any negative resident outcomes associated with staffing deficiency.

3. NHA educated DON and Scheduler on staffing ratios as of July 1st. Facility implemented process of daily scheduling meeting to ensure nursing hour coverage meets new regulation. Facility continues to hire for open LPN positions.

4. NHA will audit nursing LPN ratios daily to ensure nursing coverage meets new regulations. Findings of Audits will be submitted to QAPI for review.

5. Facility Date of Compliance will be 04/19/2024.


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