Nursing Investigation Results -

Pennsylvania Department of Health
LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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LAUREL LAKES REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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LAUREL LAKES REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on December 24, 2019, in response to five complainst, it was determined that Laurel Lakes Rehabilitation and Wellness Center 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.



 Plan of Correction:


483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.35(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 review of facility provided staffing documents, facility reports, job description, and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for five of five care units reviewed (A wing, B wing, C wing, E wing and F wing) .

Findings Include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (b). The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.

The facility's Registered Nurse Job Description last updated August 2019, reveals that within the subsection "License/Other: Must possess a current RN license in state(s) of practice.

A facility provided report revealed that on December 8, 2019, Registered Nurse 1 (RN 1), informed the facility that she had forgotten to renew her nursing license, which expired on October 31, 2019. The facility verified with the Bureau of Professional and Occupational Affairs that RN 1's nursing license was placed in the expired status as of November 1, 2019. RN 1 continued to work in the facility without a valid license from November 1, 2019 until December 8, 2019.

Review of the facility staffing documentation from November 1, 2019, until December 8, 2019, revealed that RN 1 worked 20 shifts in the facility without a valid license. Further review of the facility staffing documentation, which included deployment sheets for the facility nursing staff, time cards for RN1, and interviews with administration and the scheduling coordinator, revealed RN 1 worked November 1, 7, 8, 9, 10, 11, 12, 13, 17, 20, 21, 22, 23, 24, 25, 26, 27, and December 4, 5, and 6.

RN 1 was the only Registered Nurse in the facility on November 7, 10:00 PM to 6:00 AM, November 8, 2:00 AM to 6:00 AM, November 9, 6:00 PM to 6:00 AM, November 10, 10:00 PM to 6:00 AM, November 13, 10:00 PM to 6:00 AM, November 21, 10:00 PM to 6:00 AM, November 22, 10:00 PM to 6:00 AM, November 23, 6:00 PM to 6:00 AM, November 24, 10:00 PM to 6:00 AM, November 27, 10:00 PM to 6:00 AM, December 4, 10:00 PM to 2:00 AM, December 5, 10:00 PM to 6:00 AM, December 6, 10:00 PM to 6:00 AM, December 7, 6:00 PM to 6:00 AM and December 8, 6:00 AM to 10:00 AM.

During an interview with the Nursing Home Administrator, (NHA) and the Director of Nursing (DON) on December 19, 2019, at 1:45 PM, when asked who was responsible to check licenses to ensure they are current, they stated that no one person had been assigned the responsibility at the time of the incident.


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

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




 Plan of Correction - To be completed: 01/27/2020

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Laurel Lakes Rehabilitation & Wellness Center agrees with the allegations and citations listed on the statement of deficiencies. Laurel Lakes Rehabilitation & Wellness Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Laurel Lakes Rehabilitation & Wellness Center's written credible allegation of compliance.
By submitting this plan of correction, Laurel Lakes Rehabilitation & Wellness Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Laurel Lakes Rehabilitation & Wellness Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

Registered Nurse 1 was replaced on the nursing schedule upon discovery until her license was successfully renewed.

Facility residents have the potential to be affected by this practice. Facility Human Resources Director validated license/certification status of remaining hands-on care givers, and did not discover additional concerns.

Facility Human Resources Director has been given the responsibility to validate license/certification status, and will be re-educated concerning these requirements. Human Resources Director has established a tickler system by license/certification renewal date, will utilize it to conduct a monthly audit of upcoming renewals and report findings to the Administrator.

The results of the audits will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.70(f)(1)(2) REQUIREMENT Staff Qualifications:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.70(f) Staff qualifications.
483.70(f)(1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements.

483.70(f)(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.
Observations:

Based on review of facility provided staffing documents, facility reports, job description, and staff interviews it was determined that the facility failed to employ professionals necessary to meet the needs of the residents that were licensed or registered in accordance with applicable State laws as evidenced by one Registered Nurse not renewing her license and continuing to work, for five out of five care units (A wing, B wing, C wing, E wing and F wing) .

Findings Include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (b). The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.

The facility's Registered Nurse Job Description last updated August 2019, reveals that within the subsection "License/Other: Must possess a current RN license in state(s) of practice.

A facility provided report revealed that on December 8, 2019, Registered Nurse 1 (RN 1), informed the facility that she had forgotten to renew her nursing license, which expired on October 31, 2019. The facility verified with the Bureau of Professional and Occupational Affairs that RN 1's nursing license was placed in the expired status as of November 1, 2019. RN 1 continued to work in the facility without a valid license from November 1, 2019 until December 8, 2019.

Review of the facility staffing documentation from November 1, 2019, until December 8, 2019, revealed that RN 1 worked 20 shifts in the facility without a valid license. Further review of the facility staffing documentation, which included deployment sheets for the facility nursing staff, time cards for RN 1, and interviews with administration and the scheduling coordinator, revealed RN 1 worked November 1, 7, 8, 9, 10, 11, 12, 13, 17, 20, 21, 22, 23, 24, 25, 26, 27, and December 4, 5, and 6.

RN 1 was the only Registered Nurse in the facility on November 7, 10:00 PM to 6:00 AM, November 8, 2:00 AM to 6:00 AM, November 9, 6:00 PM to 6:00 AM, November 10, 10:00 PM to 6:00 AM, November 13, 10:00 PM to 6:00 AM, November 21, 10:00 PM to 6:00 AM, November 22, 10:00 PM to 6:00 AM, November 23, 6:00 PM to 6:00 AM, November 24, 10:00 PM to 6:00 AM, November 27, 10:00 PM to 6:00 AM, December 4, 10:00 PM to 2:00 AM, December 5, 10:00 PM to 6:00 AM, December 6, 10:00 PM to 6:00 AM, December 7, 6:00 PM to 6:00 AM and December 8, 6:00 AM to 10:00 AM.

During an interview with the Nursing Home Administrator, (NHA) and the Director of Nursing (DON) on December 19, 2019, at 1:45 PM, when asked who was responsible to check licenses to ensure they are current, they stated that no one person had been assigned the responsibility at the time of the incident.



 Plan of Correction - To be completed: 01/27/2020

Registered Nurse 1 was replaced on the nursing schedule upon discovery until her license was successfully renewed.

Facility residents have the potential to be affected by this practice. Facility Human Resources Director validated license/certification status of remaining hands-on care givers, and did not discover additional concerns.

Facility Human Resources Director has been given the responsibility to validate license/certification status, and will be re-educated concerning these requirements. Human Resources Director has established a tickler system by license/certification renewal date, will utilize it to conduct a monthly audit of upcoming renewals and report findings to the Administrator.

The results of the audits will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. 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 2.7 hours of direct resident care for each resident.
Observations:

Based on review of facility staffing schedules and staff interview, it was determined that the facility failed to provide a minimum of 2.7 hours of direct resident care for each resident for each 24 hour period for three of 21 sampled days.

Findings Include:

Review of facility staffing for the week of November 25, through December 1, 2019, revealed that on November 29, 2019, staffing hours were at 2.49.

Review of facility staffing for the week of December 12, 2019, through December 17, 2019, revealed that on December 17, 2019, staffing hours were at 2.64.

Review of facility staffing for the week of December 12, 2019, through December 17, 2019, revealed that on December 18, 2019, staffing hours were at 2.61.

During an interview with the Nursing Home Administrator on December 19, 2019, at 6:45 PM, he stated that it is his expectation that the facility meet the staffing requirements.



 Plan of Correction - To be completed: 01/27/2020

Facility Administrator, Director of Nursing and Nursing Scheduler will review the nursing schedule and staff deployment daily Monday through Friday, including projected weekend hours, to validate appropriate direct resident care hours. Adjustments will be made as necessary.

Facility residents have the potential to be affected by this practice.

Registered Nurse supervisors and nursing scheduler will be re-educated concerning these requirements, the calculation of hours and appropriate response to unplanned variation in hours. Direct care hours per resident will be audited and reported by the nursing scheduler to the Administrator and Director of Nursing during the daily staffing review. Audits will be conducted daily Monday through Friday for a period of three months.

The consolidated results of the audits will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.


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