Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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ELK HAVEN NURSING HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to a complaint completed on January 3, 2020, it was determined that Elk Haven Nursing Home 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:

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Based on review of clinical records and staff interviews, it was determined the the facility failed to provide care in accordance with the comprehensive person-centered care plan for one of 10 residents reviewed. (Resident R2)

Findings include:

Resident R2's clinical record revealed an admission date of 10/17/14, with diagnoses that included confusion, irregular heart rate, high blood pressure, long-term kidney disease, and arthritis of the bone.

Resident R2's care plan entitled Self-Care Deficit dated 10/21/14, and updated 11/26/19, identified that Resident R2 was to be transferred using a "stand-up lift."

Resident R2's clinical record also revealed that he/she had been involved in a witnessed fall on 12/02/19, in his/her bathroom while being transferred by staff. Review of documentation related to the incident revealed that one staff member stood Resident R2 up to the sink in order to assist him/her with toileting. Resident R2 let go of the sink and fell back against the wall of the bathroom.

During an interview on 1/02/20, at 2:30 p.m. Nurse Aide Employee E1 confirmed that he/she transferred Resident R2 with the assistance of one other employee only and did not use the lift.

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

28 Pa Code 211.11(d) Resident care plans

 Plan of Correction - To be completed: 01/28/2020

Employee E1 educated by Director of Nursing on 01/15/2020 regarding resident's transfer status and following resident care plans.

Education to be provided to nursing staff on 01/15/2020, 01/16/2020 and 01/17/2020 regarding following resident care plans. All seasonal and per diem staff to be educated prior to working next scheduled shift.

Director of Nursing/designee will complete audits of 12 residents once weekly x 3 weeks, once monthly x 3 months, and once quarterly x1 quarter to ensure staff are following resident care plans in regards to transfer status.

Audit results will be reviewed by the Quality Assurance Performance Improvement Committee with determination of the need for continued audits.

Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared and/or executed solely because it is required by the provisions of the Federal and State law.

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