Pennsylvania Department of Health
ABINGTON MANOR
Patient Care Inspection Results

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ABINGTON MANOR
Inspection Results For:

There are  107 surveys for this facility. Please select a date to view the survey results.

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ABINGTON MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on April 4, 2024, it was determined that Abington 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
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 and select resident incident/accident reports and staff interview, it was determined that the facility failed to provide adequate staff supervision to timely identify a resident's unauthorized absence from the facility to assure the safety of one resident (Resident 1) and failed to consistently implement planned safety measures, including necessary staff supervision, to prevent a fall for one resident out of four sampled (Resident 2)

Findings include:

A review of the clinical record revealed that Resident 2 was admitted to the facility on June 2, 2021, with diagnoses of Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown) and mild dementia ( a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with behavior disturbance

A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated December 15, 2023, revealed that the resident was severely cognitively impaired with a BIMS of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00 - 07 equates to severe cognitive impairment) and required extensive assistance of two staff for activities of daily living.

A fall risk assessment dated January 13, 2024, indicated that the resident was at high risk for falls. Care planned interventions on this date were the use of bed alarm while in bed, call bell in reach, encourage to transfer and change positions slowly, fall mats to both sides of bed, provide assistance to transfer and ambulate as needed. Staff were to check the resident's bed alarm and chair alarm every shift and as needed.

Documentation in Resident 2's clinical record dated February 26, 2024, at 3:00 PM revealed a nurse aide, Employee 7 heard a loud yell and a bang and responded to the resident dining/day room. Employee 7 found Resident 2 on the floor, on the resident's left side, bleeding from his right hand and blood on the floor. Upon nursing assessment, the resident was identified to have an an open area to his right hand on his fourth finger with tendons exposed measuring 1 cm x 1.5 cm x 0.1 cm. The resident was sent to the hospital, received three sutures to close the wound and returned to the facility.

A review of the facility's investigation into the resident's fall, revealed a statement from Employee 8, the nurse aide responsible for Resident 2's care on February 26, 2024, indicating that she, along with another staff member, assisted the resident into his wheelchair because he was climbing out of bed. She stated she forgot to put the chair alarm on his wheelchair . She placed him in the dining room. Employee 8 stated she last saw the resident at 1:00 PM sitting in the dining room at 1:00 PM. At 2:50 PM staff found the resident on the floor of the dining room/day room. The resident along with another resident were in the dining room unsupervised. No facility staff were present in the dining room/day room at that time.

Interview with the assistant director of nursing on April 3, 2024, at 3:00 PM confirmed the facility failed to implement planned safety interventions and provide adequate staff supervision to prevent Resident 2's fall with minor injury.

Clinical record review revealed Resident 1 was admitted to the facility on August 9, 2023 with diagnoses of insulin dependent diabetes mellitus (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period, unspecified visual disturbance, cataract removal, and cerebral ischemia (in which there is insufficient blood flow to the brain to meet metabolic demand. This leads to poor oxygen supply or cerebral hypoxia and this leads to death of brain tissue. It is a subtype of stroke).

A review of this resident's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 13, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). The resident was independent with ambulation and activities of daily living.

Interview with multiple facility staff members who wish to remain anonymous for fear of retaliation, on April 3, 2024, at approximately 8:30 AM revealed that staff were unable to locate Resident 1 in the facility for many hours on Easter Sunday March 31, 2024.

A telephone interview with Employee 6 an RN on April 3, 2024 at approximately 2:00 PM revealed that she received a telephone call from the nurse practitioner in the facility (CRNP) on March 31, 2024, at 5:45 PM inquiring if she had seen Resident 1 and another call at 6:15 PM from the ADON inquiring about Resident 1's whereabouts. Employee 6 replied by suggesting that they check the casino because the resident had been known to frequent the local casino.

A late note entered by the ADON (assistant director of nursing) in Resident 1's clinical record on April 1, 2024, at 6:45 PM indicated that Resident 1 was discharged from the facility.
An order written by the CRNP dated April 1, 2024, indicated that the resident was discharged from facility on March 31, 2024, with home health services.

A review of the resident's medication administration record (MAR) for March 31, 2024 revealed he received his 6:00 AM medications but staff did not administer his scheduled medications at 9 AM, 5 PM, and 9 PM.

According to the NHA and ADON during an interview on April 3, 2024 at approximately 11:00 AM the ADON stated she received a call from the facility staff on March 31, 2024 approximately 5:30 PM indicating that Resident 1 was not in the building and he did not sign out as a leave of absence (LOA). She stated she contacted the NHA. The facility's Social Worker stated she knew he was at the casino however, but did not know how he got there or when he left the building. The NHA stated she called the casino and they confirmed he was there. The Social Worker and the RNAC (registered nurse assessment coordinator) traveled to the casino and met the ADON there, around 6:30 PM on March 31, 2024. The resident was located and he stated he did not want to return to the facility because he had three nights of a hotel stay which was paid for by the casino. The ADON and the Social Worker had the resident sign a paper, created in handwriting which stated "I \ am signing myself out of \ against medical advice (AMA) on March 31, 2024. I am signing out against medical advice despite being educated on the risks and consequences." This handwritten form was signed by the ADON and Social Worker. They stated the resident left the facility at approximately 10:30 AM and was appropriately discharged.

A telephone interview on April 3, 2024 at 11:30 AM with Employee 1 a Registered Nurse who was assigned to this resident on March 31, 2024, revealed she did not arrive at the facility that day (March 31, 2024) until 9:00 AM . She stated she relieved Employee 2 who had possession of the medication cart at the time. Employee 1 stated she didn't see Resident 1. She stated she wasn't concerned about the resident's medication administration scheduled for 9 AM, because Resident 1 usually came to her for his medication. She stated she disposed of his medication that wasn't given and when her shift was over at 3:00 PM she left the resident's unit to work from 3:00 PM to 11:00 PM on another unit. She stated she did not see the resident from the time she arrived on duty at 9:00 AM and did not report his absence to anyone because she was responsible for 28 residents and he was "someone that always showed up." Employee 1 confirmed, however, that she did not know where the resident was during her shift.

A telephone interview with Employee 4, a nurse aide, on April 3, 2024, at 11:35 AM Employee 4 confirmed Resident 1 was on her assignment that day. She stated that she saw Resident 1 at the very beginning of her shift at approximately 9:30 AM and did not see him after that time. When asked about the resident's lunch meal and if she attempted to locate the resident to have lunch on the date, she stated "It was too too busy! A lot going on! No time to do books!"

Employee 3, a licensed practical nurse (LPN) as per written statement indicated that she went to Resident 1's room at 4:30 PM to get his Accucheck and she noticed that his lunch tray was on his bedside table untouched. She stated she asked some of the nurse aides if they knew where the resident was and they said no. She looked into the LOA book to see if he signed out for the day and there was nothing signed out. She then went to the supervisor. The RN supervisor, Employee 5, and told her she could not find Resident 1.

During an interview with the RN Supervisor Employee 5 on April 3, 2024 at 2:45 PM she stated Employee 3 notified her that Resident 1 was not available for his Accucheck and his lunch tray was in his room untouched on March 31, 2024, at approximately 4:30 PM. Employee 5 indicated she contacted the ADON and began to search the grounds for him. She stated they checked the whole building and could not locate him. She learned later on that evening that he was located at the casino.

During an interview on April 3, 2024 at approximately 3:00 PM, the Nursing Home Administrator and the ADON confirmed that on March 31, 2024, during the 7:00 AM to 3:00 PM shift nursing staff failed to adequately supervise Resident 1 and were unaware of his whereabouts during that shift to assure that the resident was safe.

Refer F725

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







 Plan of Correction - To be completed: 05/28/2024

1. Resident #2: CNA educated for failure to follow care plan safety intervention measures. Resident #1: CNA and RN educated for failure to know of resident's whereabouts during scheduled shift.
2. Facility house audit will be conducted to identify current residents with alarms in place to ensure functioning and proper placement. Facility house Elopement Assessment will be conducted to identify any residents at risk.
3. Unit managers/Designees will educate nursing staff on the Policy for Accidents and Incidents-Investigating and Reporting. Unit managers/Designees will complete alarm audit for 10 sample residents 3x-week for 4 weeks to ensure alarm is in place and functioning correctly. Unit managers/Designees will audit 5 sample residents at risk for elopement 3x-week for 4 weeks to ensure appropriate interventions are documented on the care plan.
4. The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observations, a review of clinical records, and staff interviews it was determined the facility failed to provide sufficient nursing staff to consistently provide timely care and supervision necessary to maintain the physical and mental well-being of two the four residents sampled (Resident 1)

Findings include:

A review of the clinical record revealed that Resident 2 was admitted to the facility on June 2, 2021, with diagnoses of Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown) and mild dementia ( a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with behavior disturbance

A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated December 15, 2023, revealed that the resident was severely cognitively impaired with a BIMS of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00 - 07 equates to severe cognitive impairment) and required extensive assistance of two staff for activities of daily living.

A fall risk assessment dated January 13, 2024, indicated that the resident was at high risk for falls. Care planned interventions on this date were the use of bed alarm while in bed, call bell in reach, encourage to transfer and change positions slowly, fall mats to both sides of bed, provide assistance to transfer and ambulate as needed. Staff were to check the resident's bed alarm and chair alarm every shift and as needed.

Documentation in Resident 2's clinical record dated February 26, 2024, at 3:00 PM revealed a nurse aide, Employee 7 heard a loud yell and a bang and responded to the resident dining/day room. Employee 7 found Resident 2 on the floor, on the resident's left side, bleeding from his right hand and blood on the floor. Upon nursing assessment, the resident was identified to have an an open area to his right hand on his fourth finger with tendons exposed measuring 1 cm x 1.5 cm x 0.1 cm. The resident was sent to the hospital, received three sutures to close the wound and returned to the facility.

A review of the facility's investigation into the resident's fall, revealed a statement from Employee 8, the nurse aide responsible for Resident 2's care on February 26, 2024, indicating that she, along with another staff member, assisted the resident into his wheelchair because he was climbing out of bed. She stated she forgot to put the chair alarm on his wheelchair . She placed him in the dining room. Employee 8 stated she last saw the resident at 1:00 PM sitting in the dining room at 1:00 PM. At 2:50 PM staff found the resident on the floor of the dining room/day room. The resident along with another resident were in the dining room unsupervised. No facility staff were present in the dining room/day room at that time.

Interview with the assistant director of nursing on April 3, 2024, at 3:00 PM confirmed the facility failed to implement planned safety interventions and provide adequate staff supervision to prevent Resident 2's fall with minor injury.

Clinical record review revealed Resident 1 was admitted to the facility on August 9, 2023 with diagnoses of insulin dependent diabetes mellitus (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period, unspecified visual disturbance, cataract removal, and cerebral ischemia (in which there is insufficient blood flow to the brain to meet metabolic demand. This leads to poor oxygen supply or cerebral hypoxia and this leads to death of brain tissue. It is a subtype of stroke).

A review of this resident's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 13, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). The resident was independent with ambulation and activities of daily living.

Interview with multiple facility staff members who wish to remain anonymous for fear of retaliation, on April 3, 2024, at approximately 8:30 AM revealed that staff were unable to locate Resident 1 in the facility for many hours on Easter Sunday March 31, 2024.

A telephone interview with Employee 6 an RN on April 3, 2024 at approximately 2:00 PM revealed that she received a telephone call from the nurse practitioner in the facility (CRNP) on March 31, 2024, at 5:45 PM inquiring if she had seen Resident 1 and another call at 6:15 PM from the ADON inquiring about Resident 1's whereabouts. Employee 6 replied by suggesting that they check the casino because the resident had been known to frequent the local casino.

A late note entered by the ADON (assistant director of nursing) in Resident 1's clinical record on April 1, 2024, at 6:45 PM indicated that Resident 1 was discharged from the facility.
An order written by the CRNP dated April 1, 2024, indicated that the resident was discharged from facility on March 31, 2024, with home health services.

A review of the resident's medication administration record (MAR) for March 31, 2024 revealed he received his 6:00 AM medications but staff did not administer his scheduled medications at 9 AM, 5 PM, and 9 PM.

According to the resident's March 2024 MAR the resident did not receive the following medications as scheduled at 9 AM, 5 PM and 9 PM on March 31, 2024:

Amlodipine 2.5 mg by mouth for hypertension at 9 AM
Ascorbic Acid 600 mg by mouth as a supplement at 9 AM
Cyanocobalamin 600 mg by mouth for anemia at 9 AM
Eucerin Cream to upper arms for itching at 9 AM
Ferrous Sulfate 326 mg one tablet by mouth for anemia at 9 AM
Aspirin 81 mg one tablet by mouth at 5 PM (documented as given but determined it was not because the resident was not present in the facility)
Magnesium Oxide 40 mg by mouth at 9 AM and 5 PM
Metformin HCL 500mg by mouth at 7:30 AM and 5 PM (staff documented that the 5 PM dose was given but was not because the resident was not in the facility at that time)
Atorvastatin Calcium 40 mg one tablet for elevated cholesterol at 9 PM
Fiasp Flex Touch Insulin 100 units/ML 5 units before meals and at bedtime
Basaglar Kwik-Pen 100 units/ML insulin 20 units at 9 PM
Blood sugars ordered 11 AM 5PM and 9 PM

According to the NHA and ADON during an interview on April 3, 2024 at approximately 11:00 AM the ADON stated she received a call from the facility staff on March 31, 2024 approximately 5:30 PM indicating that Resident 1 was not in the building and he did not sign out as a leave of absence (LOA). She stated she contacted the NHA. The facility's Social Worker stated she knew he was at the casino however, but did not know how he got there or when he left the building. The NHA stated she called the casino and they confirmed he was there. The Social Worker and the RNAC (registered nurse assessment coordinator) traveled to the casino and met the ADON there, around 6:30 PM on March 31, 2024. The resident was located and he stated he did not want to return to the facility because he had three nights of a hotel stay which was paid for by the casino. The ADON and the Social Worker had the resident sign a paper, created in handwriting which stated "I \ am signing myself out of \ against medical advice (AMA) on March 31, 2024. I am signing out against medical advice despite being educated on the risks and consequences." This handwritten form was signed by the ADON and Social Worker. They stated the resident left the facility at approximately 10:30 AM and was appropriately discharged.

A telephone interview on April 3, 2024 at 11:30 AM with Employee 1 a Registered Nurse who was assigned to this resident on March 31, 2024, revealed she did not arrive at the facility that day (March 31, 2024) until 9:00 AM . She stated she relieved Employee 2 who had possession of the medication cart at the time. Employee 1 stated she didn't see Resident 1. She stated she wasn't concerned about the resident's medication administration scheduled for 9 AM, because Resident 1 usually came to her for his medication. She stated she disposed of his medication that wasn't given and when her shift was over at 3:00 PM she left the resident's unit to work from 3:00 PM to 11:00 PM on another unit. She stated she did not see the resident from the time she arrived on duty at 9:00 AM and did not report his absence to anyone because she was responsible for 28 residents and he was "someone that always showed up." Employee 1 confirmed, however, that she did not know where the resident was during her shift.

A telephone interview with Employee 4, a nurse aide, on April 3, 2024, at 11:35 AM Employee 4 confirmed Resident 1 was on her assignment that day. She stated that she saw Resident 1 at the very beginning of her shift at approximately 9:30 AM and did not see him after that time. When asked about the resident's lunch meal and if she attempted to locate the resident to have lunch on the date, she stated "It was too too busy! A lot going on! No time to do books!"

Employee 3, a licensed practical nurse (LPN) as per written statement indicated that she went to Resident 1's room at 4:30 PM to get his Accucheck and she noticed that his lunch tray was on his bedside table untouched. She stated she asked some of the nurse aides if they knew where the resident was and they said no. She looked into the LOA book to see if he signed out for the day and there was nothing signed out. She then went to the supervisor. The RN supervisor, Employee 5, and told her she could not find Resident 1.

During an interview with the RN Supervisor. Employee 5, on April 3, 2024 at 2:45 PM she stated Employee 3 notified her that Resident 1 was not available for his Accucheck and his lunch tray was in his room untouched on March 31, 2024, at approximately 4:30 PM. Employee 5 indicated she contacted the ADON and began to search the grounds for him. She stated they checked the whole building and could not locate him. She learned later on that evening that he was located at the casino.

A review of nurse staffing for the 3 west resident unit on which Resident 1 resided, on March 31, 2024, during the 7:00 AM to 3:00 PM shift revealed that staffing was 1 RN, 1 LPN who arrived at 9:00 AM and 2 nurse aides. The resident census was 29 residents on the 3 W resident unit. However, the available staff failed to adequately supervise Resident 1's whereabouts to provide the resident's medications, blood sugar monitoring, nursing care, and meals.

During an interview on April 3, 2024 at approximately 3:00 PM, the Nursing Home Administrator and the ADON confirmed that the facility was unable to demonstrate the provision of sufficient nursing staff to supervise and provide care as planned and ordered to Resident 1 on March 31, 2024, during the 7:00 AM to 3:00 PM shift.

Refer F689

28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services

28 Pa. Code 201.18 (e)(1)(6) Management





 Plan of Correction - To be completed: 05/28/2024

1.The facility has implemented a recruitment plan including a wage increase, revamped orientation process, internal incentives, and a check-in system for open communication with direct care staff and department managers to improve recruitment and retention.
2. The Facility Assessment will be reviewed to ensure the acuity of the residents matches our orientation education and clinical staffing capabilities.
3. Interviews with nursing staff will be conducted weekly x3 to ensure they feel they have enough time to provide direct care services to the residents. Interviews with samples of residents and R/P's will be conducted weekly x3 to ensure residents and R/P's feel satisfied with the nursing staff's responsiveness to request for assistance.
4.The Administrator/designee will present the results of these interviews at the Quality Assurance and Performance Committee monthly for further review and recommendations.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(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 review of clinical records and select reports and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of four sampled residents (Resident 1).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct. (a) A licensed practical nurse shall: (5) Document and maintain accurate records. (b) A licensed practical nurse may not: (8) Falsify or knowingly make incorrect entries into the patient's record other related documents.


Employee 3, a licensed practical nurse (LPN), wrote in an witness statement that she went to Resident 1's room at 4:30 PM on March 31, 2024 to get his Accucheck and she noticed that his lunch tray was on his bedside table untouched. She stated she asked some of the nurse aides if they knew where the resident was and they said no. She looked into the LOA book to see if he signed out for the day and there was nothing signed out. She then went to the RN supervisor, Employee 5, and told her she could not find Resident 1.

A review of Resident 1's MAR (medication administration record) dated for March 31, 2024 revealed Employee 3, an LPN (licensed practical nurse) administered Resident 1's Aspirin 81 mg by mouth and Metformin HL 500 mg one tablet by mouth at 5:00 PM as indicated by her initials indicating they were administered.

However, according to interviews with facility staff on April 3, 2024, and a review of the facility's documentation and resident clinical record revealed that Resident 1 was not in the facility at 5 PM on March 31, 2024, and did not receive any medications after 6 AM on that date. Employee 3 reported resident's absence to the RN Supervision on March 31, 2024, at approximately 4:30 PM but documented that she adminstered his medications at 5 PM when the resident was not present in the facility.

Interview with the ADON (assistant director of nursing) on April 3, 2024, at 3:00PM confirmed that Employee 3 did not administer the 5 PM medications to Resident 1 as documented on the resident's MAR.


Refer F725

28 Pa. Code 211.5 (f) Medical records.

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




 Plan of Correction - To be completed: 05/28/2024

1. LPN educated on the Medication Administration Policy.
2. Facility house audit to be conducted with capable residents to ensure they received their medications as scheduled.
3. Unit manager/designees will educate licensed nurses on Medication Administration Policy. Audits will be conducted for 10 sample residents 3x- week for 4 weeks of capable residents to ensure they are receiving their scheduled medications.
4. The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on a review of clinical records and interview with facility staff, it was determined that the facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities of events with the potential to compromise resident health and safety as evidenced by one of four residents sampled (Resident 1).

Findings include:

Under the 28 PA Code 201.3 an elopement is defined as when a resident leaves the premises or a safe area without authorization.

Clinical record review revealed Resident 1 was admitted to the facility on August 9, 2023 with diagnoses of insulin dependent diabetes mellitus (commonly referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period, unspecified visual disturbance, cataract removal, and cerebral ischemia (in which there is insufficient blood flow to the brain to meet metabolic demand. This leads to poor oxygen supply or cerebral hypoxia and this leads to death of brain tissue. It is a subtype of stroke).

During interviews with staff on April 3, 2024, it was determined that on March 31, 2024, the facility was unaware that Resident 1 left the facility for approximately nine hours. The facility did not identify the resident's absence until approximately March 31, 2024, at 4:30 PM.
Review of his clinical record revealed he did not receive any medications after 6:00 AM and his lunch meal went untouched. The resident was eventually located at the casino after 6:00 PM in the evening of March 31, 2024.

Interview with the nursing home administrator and assistant director of nursing at 3:00 PM on April 3, 2024 confirmed they did not report the incident of elopement to the State Licensing Agency Division of Nursing Care Facilities because their corporation advised that them, not to report because the resident was subsequently dischaged when located.





 Plan of Correction - To be completed: 05/28/2024

1.Facility reported the incident of elopement to the State Licensing Agency Division of Nursing Care Facilities.
2. Facility will conduct house audit to ensure no other elopement incidents have failed to be reported.
3.NHA/DON/ADON have been educated on reporting incidents of elopement to the State Licensing Agency Division of Nursing Care Facilities.
4. The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for two shifts out of 24 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

March 31, 2024 - 4.17 LPNs on the day shift versus the required 4.28 for a census of 107
March 31, 2024 - 2.25 LPNs on the night shift, versus the required 2.68 for a census of 107.


An interview with the Nursing Home Administrator on April 3, 2024, approximately 3:00 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.



 Plan of Correction - To be completed: 05/28/2024

1.The facility will provide staffing at 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 to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday-Friday, to include projected weekend ratios, to validate appropriate direct resident care ratios. Adjustments will be made as necessary.
2.Schedule is completed daily and staffed with 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. When absences occur, every effort is made to replace staff.
3.The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum LPN ratios and the appropriate response to unplanned variations in hours. Ratios will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that correct LPN ratios are maintained.
4.The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing, resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing levels dated March 26, 2024 through April 1, 2024 revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

March 28, 2024 -2.53 direct care nursing hours per resident
March 30, 2024 - 2.60 direct care nursing hours per resident
March 31, 2024 - 2.38 direct care nursing hours per resident
April 1, 2024 - 2.75 direct care nursing hours per resident

An interview with the Nursing Home Administrator on April 3, 2024, at approximately 3:00 PM confirmed that the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 05/28/2024

1.The facility will provide staffing at a minimum of 2.87 hour per patient day to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday through Friday, to include projected weekend hours, to validate appropriate direct resident care hours. Adjustments will be made as necessary.
2.Schedule is completed daily and staffed with a minimum of 2.87 PPD. When absences occur, every effort is made to replace staff.
3.The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum nursing staffing hours and the appropriate response to unplanned variations in hours. Direct care hours will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that 2.87 hours of direct resident care is maintained.
4.The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.


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