Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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FREY VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on February 19, 2020, it was determined that Frey Village 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 related to the health portion of the survey process.

 Plan of Correction:

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Based on a clinical record review and staff interview, it was determined the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for one of five residents reviewed (Resident 2).

Findings include:

Review of Resident 2's clinical record revealed he had been admitted to the facility in November 2018, with diagnoses that included Unspecified Dementia with behavioral disturbances (an irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability) and chronic obstructive pulmonary disease (COP- a disease process that causes decreased ability of the lungs to perform).

Review of Resident 2's care plan included the following focus areas: alteration in elimination of bowel and bladder, frequently incontinent. One of the interventions listed is "toileting every 2-3 hours and as needed, needs extensive assist with toileting" and non-compliance with transfers for which an interventions is listed to be "redirect resident if he appears to want ot transfer himself"

Review of Resident 2's significant change Minimum Data Set (MDS-a periodic assessment of resident's needs), dated December 11, 2019 indicates that for toilet use resident requires the extensive assistance of 2 or more persons physical assist.

Review of the facility's Incident Reporting and Investigation Tool dated December 16, 2019 revealed that Resident 2 was taken to the bathroom by Nurse Aide (NA) 1 in order to prepare to toilet him when he tried to stand without prompting. He began to stand and his knees buckled when NA 1 lowered him to the floor. The incident report includes a "Disciplinary Action Memorandum" dated December 16, 2019 which states that "On December 16, 2019 (NA 1) assisted a resident after he stood without direction in the bathroom which resulted in the resident being lowered to the floor. Instead of assisting the resident to a safe position and await help, (NA 1) completed care. The resident wasn't injured." The Memorandum states that NA 1 should prepare for resident care prior to placing a resident in the environment to do care. And that if a resdient attempts to stand or transfer against their orders, staff need to assist the resident to a safe location or position to get help. The action plan on the Memorandum was that NA 1 will complete transfer education by December 31, 2019.

During an interview with the Nursing Home Administrator on February 21, 2020, at approximately 2:45 PM, she affirmed that the aforementioned incident occurred and that the facility took steps to education the staff person involved.

28 Pa Code 211.11(a) (d) Resident care plan

 Plan of Correction - To be completed: 03/19/2020

1. The staff member was educated and corrective actions were taken, Resident 2 was not harmed.
2. A review was completed of residents who require 2 assistants for care and re-educated staff on assuring 2 staff are present to initiate care.
3. During IDT meeting, care plan compliance will be reviewed for residents at risk. If discrepancies are identified the Unit Manager or designee will address with staff and re-educate.
4. Unit Manager or designee will perform 10 random audits to assure that 2 staff members are providing care for residents who require that level of care. Weekly audits will be performed x 4 weeks and information will be submitted to QAPI for review and recommendations

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