Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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QUALITY LIFE SERVICES - HENRY CLAY - 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 April 1, 2024, it was determined that Quality Life Services - Henry Clay 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 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(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.
Based on review of facility policy, facility submitted documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one out of 12 residents reviewed (Resident R1).

Findings include:

The facility "Accidents and Incidents" policy dated 1/25/24, indicated that it is the policy of the facility to promote a safe environment for all residents.

Review of the clinical record indicated Resident R1 was admitted to the facility on 12/11/23, with diagnoses that included cerebral infarct (stroke - interruption of blood flow within your brain that causes death of brain cells), hemiplegia (paralysis or weakness of one side of the body) affecting right dominant side, and aphasia (comprehension and communication -reading, speaking, or writing - disorder resulting from damage or injury to the specific area in the brain).

Review of Resident R1's Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 2/8/24, indicated that the diagnoses were current upon review.

Review of a physician order dated 2/27/24, indicated for Resident R1 to have built up red foam utensil and divided plate for all meals. Further review indicated the order was updated following the incident to include using a sip-a-cup for hot beverages.

Review of the Kardex dated 3/10/24, indicated eating/swallowing to maintain current level of function and prevent avoidable decline.

Review of the care plan dated 12/8/23, indicated to engage in simple, structured activities that avoid overly demanding tasks, anticipate needs and meet them, ensure to provide a safe environment: make sure call light is always in reach, and that he is not isolated, and encourage to participate to the fullest extent possible.

Review of a facility submitted documents dated 3/10/24, indicated Resident R1 was given a cup of coffee in a styrofoam cup during the Coffee Club activity. The cup was placed in the resident's left hand (non-dominant) and spilled the coffee on himself resulting in two areas of redness on his abdomen measuring 10.0 centimeters (cm) by 5.0 cm, and 5.0 cm by 5.0 cm. The resident had on a cloth clothing protector and a t-shirt. Resident R1's skin remained intact.

During an interview on 4/1/24, at 11:08 a.m. Activity Director, Employee E1 stated she was not working the date of the incident. She stated the Coffee Club coffee was provided by the kitchen on 3/10/24, and usually everyone gets styrofoam cups, and Resident R1 does not usually come to the activity. The activity takes place in the East Dining Room for all residents that wish to attend.

During a telephone interview on 4/1/24, at 11:30 a.m. Activities Aide Employee E2 stated she worked the day of the incident and Resident R1 was not brought to Coffee Club activity. He was brought to the Resident Lounge by the Nurse Aid (NA) Employee E3. She served coffee to the residents involved in the activity, a nurse aide came in and asked if Resident R1 could get a coffee, and a coffee was provided to NA Employee E3 to give to Resident R1.

During an telephone interview on 4/1/24, at 12:15 p.m. NA Employee E3 stated Resident R1 was brought to the resident lounge to watch television. When he saw the coffee being delivered to the activity he started pointing and screaming. Resident R1 is unable to speak. Resident R1 was holding the coffee in his left hand and sipping at it. Other resident's in the lounge stated they wanted coffee also, so NA Employee E3 returned to the East Dining Room to obtain more coffee, when she heard Resident R1 yell out. She states she put down the other resident's coffee and went out of the dining room into the lounge, and saw Resident R1 had spilled his coffee on himself. NA Employee E3 stated Resident R1 has previously held styrofoam cups of hot chocolate with no issues. She moved the soaked clothing away from Resident R1's skin and notified nursing.

During an interview on 4/1/24, at 1:11 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain Resident R1 received adequate supervision and assistance to prevent accidents as required.

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

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

28 Pa. Code: 211.10(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

 Plan of Correction - To be completed: 05/03/2024

All staff received education on 04/04/2024 regarding the use of all ordered adaptive equipment and supervision when serving hot beverages or food during group activity or events.

Thermometers were provided in each dining room on 04/04/2024 to be used when heating any hot liquids or food to be served to residents that isn't prepared from the dietary department. Staff received education regarding safe temperatures of food at 165 degrees and hot beverages no more than 150 degrees. Education was completed on 04/04/2024.

Dietary received education on 03/10/2024 by administrator and 04/09/2024 by Registered Dietician that coffee and hot water will be checked with a thermometer and recorded prior to leaving the kitchen. The recommended temperatures should not be more than 150 degrees. All temperature logs will be reviewed and maintained by dietary manager weekly and administrator will review audit at scheduled QAPI meetings to maintain on-going compliance. Administration and or designee will complete a daily audit for 2 weeks then 2 times a week at all group activities or special events. All audits and temperature logs will be reviewed at monthly QAPI meetings to maintain compliance.

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