Nursing Investigation Results -

Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

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AVENTURA AT CREEKSIDE
Inspection Results For:

There are  105 surveys for this facility. Please select a date to view the survey results.

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AVENTURA AT CREEKSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on June 14, 2022, it was determined that Aventura at Creekside 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:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):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.
483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:
Based on a review of clinical records, select facility policy and staff CPR training and certification information and staff interviews it was determined that the facility failed to ensure that all staff providing CPR were properly trained and/or qualified to perform cardiopulmonary resuscitation desired by one resident out of five residents reviewed (Resident CR1).

Findings include:

Review of the facility's policy and procedure titled "CPR Policy and Procedure" provided at the time of the survey ending June 14, 2022, revealed that the purpose of the procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. It is the facility policy to obtain and/ or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including unlicensed staff. Additionally, the policy indicated that if an individual (resident) is found unresponsive and without a pulse, a licensed staff person who is certified in CPR/BLS shall initiate CPR: in the absence of advanced directives, unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or unless there are obvious signs of irreversible death (e.g., rigor mortis, dependent lividity).

A review of Resident CR1's clinical record revealed admission to the facility on September 1, 2020, with multiple diagnoses including chronic respiratory failure, Chronic Obstructive pulmonary disease and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

The clinical record indicated that the resident was a FULL CODE, indicating the resident's wish to receive CPR and Life Support measures in the event the resident suffers a witnessed cardiac arrest (a condition in which the heart suddenly and unexpectedly stops beating) and/or he/she ceases to breathe.

Review of a progress note dated May 31, 2022, at 0316 (3:16 AM) revealed, "Patient was observed by CNA upon making rounds to be unresponsive at 2:40 AM CPR initiated, 911 called arrived at 2:50 AM epinephrine, narcon (Narcan, spelled wrong in record) was administered. At 3:05 AM patient was pronounced by, (physician's name). Patient's brother was called no answer".

There was no documented evidence available during the survey of June 14, 2022, to identify which staff member(s) had initiated and provided CPR to the resident while awaiting emergency services personnel. (Regulatory requirements require that facilities must have systems in place supported by policies and procedures to ensure there are an adequate number of staff present at all times who are properly trained and/or certified in CPR for Healthcare Providers to be able to provide CPR until emergency medical services arrives. Facility policies should address the provision of basic life support and CPR, including ensuring staff receive certification in performance of CPR (CPR for Healthcare Providers).

Interview with the Nursing Home Administrator and Director of Nursing on June 14, 2022 at approximately 11:00 AM revealed he was unaware of which staff members had provided CPR to Resident CR1 to ensure that these staff members were properly trained and/or certified to perform CPR.

The DON stated during interview on June 14, 2022, that the facility would not list employees names in the resident's clinical record, but she was also unaware of which staff members had provided CPR to Resident CR1 to ensure that they were properly trained and/or certified.

Interview with Employee 1, a Nurse Aide, on June 14, 2022 at 1:15 PM revealed that she provided CPR to Resident CR1 at some point while awaiting EMS. Employee 1 stated that most of the nursing staff on duty had performed CPR on the resident while waiting for EMS. Employee 1 was unable to state who had initiated CPR. Employee 1 stated that she was certified to provide CPR, but did not obtain her certification or training at the facility. However, at the time of the survey ending June 14, 2022, the facility was unable to provide documented evidence that Employee 1 was properly trained and/or certified to provide CPR.

Interview with Employee 2, a Licensed Practical Nurse, on June 14, 2022, at 1:20 PM revealed he was on lunch in his car, when Employee 3, RN, asked that he return to the building from his car to assist with Resident CR1's CPR. Employee 2 stated that he also provided CPR to the resident during the wait for EMS. The facility was able to provide documentation of Employee 2's training and CPR certification at the time of the survey.

Interview with Employee 3, Registered Nurse Supervisor, revealed Employee 1 retrieved her from the nurses station in response to Resident CR1's status. Upon entering the room Employee 4, nurse aide was rendering CPR to the resident. Employee 3 stated that she directed staff to call 911 and retrieved the AED and applied it to the resident's chest. Employee 3 stated that the AED indicated no shock was advised and to continue CPR.

Interview with Employee 6, a nurse aide, revealed she had provided CPR to the resident that night as well. Employee 6 stated that "everyone" assisted. Employee 6 stated that herself and Employees 1, 2, 3, 4,and 5 provided CPR to the resident. During interview on June 14, 2022, Employee 6 stated that she was unsure if she was qualified to perform CPR.

Review of Employee 4's (nurse aide) witness statement provided by the facility on June 16, 2022 revealed Employee 4 stated that Employee 5, a Nurse Aide, went to the nurses station and informed Employee 3, RNS, that Resident CR1 was unresponsive. Employee 4 stated that Employee 3, RNS instructed the nurse aides, Employees 4 and 5, to perform CPR on Resident CR1

At the time of the survey ending June 14, 2022, the facility failed to provide documented evidence that Employees 1, 4, 5, and 6 were properly trained and/or certified to perform CPR.

Interview with the Nursing Home Administrator on June 14, 2022, confirmed that the facility was unaware of the training and CPR certification of the staff members who had provided CPR to Resident CR1. The NHA was unable to provide documented evidence of all staff that rendered CPR were properly trained and/or certified in the administration of CPR.


Refer to 842


28 Pa Code 201.29 (a)(d) Resident rights.

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20 (d) Staff development

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

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






















 Plan of Correction - To be completed: 07/12/2022

Preparation and/or execution of this Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed because it is required by the provision of federal and state law.
1. The individual is deceased and therefore the deficiency cannot be corrected as it relates to the resident.
2. The facility scheduled a CPR training available to all direct care staff. Staff will review and sign off on the CPR policy, acknowledging that in order for the facility to consider them certified we must have a copy of the actual card on file in their chart, and that if we do not have a valid copy of this certification they are under no circumstances to perform CPR in the facility.
3. Nursing staff and nursing assistants will be educated on our CPR policy. The policy will highlight the fact that no staff is to conduct CPR if they are not certified and have a copy of that certification on file at the time of performing CPR
4. An audit will be conducted weekly X 4 and monthly X2 to ensure that new staff is educated on the CPR policy and that they are routinely being offered CPR training. Results of this audit will be submitted and discussed in QA.

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 a review of select facility policy and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to accurately document care and services provided to one resident of five sampled ( Resident CR1).

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, Communications with and education of the patient, family, and the patient's designated support person and other third parties.


Review of facility policy provided at the time of the survey ending June 14, 202, entitled: "Emergency Response Guidelines", indicated that it is the policy of the facility that guidelines are to be utilized in the event of a resident emergency. Step 7 of the guidelines indicated that staff are to "Chart completely all events leading up to the situation, what transpired during the situation, and the events that followed. All of this information along with the date, time and the nurse's signature should be documented in the narrative nurse's notes."

Review of facility policy provided at the time of the survey ending June 14, 2022, entitled:" CPR Policy & Procedure", revealed that the purpose of the procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. The policy indicates document the following in the resident's medical record (if the victim is a resident).
"The condition in which the resident was found in or the witnessed event
"The sequence of resuscitation efforts, including approximate times.
"The victims response
"The approximate time that EMS team took over
"Time of death or time the individual was transported.

Review of Resident CR1's clinical record revealed a progress note written by Employee 3, RN, dated May 31, 2022, at 0316 (3:16 AM) revealed, "Patient was observed by CNA upon making rounds to be unresponsive at 2:40 AM CPR initiated, 911 called arrived at 2:50 AM epinephrine, narcon (Narcan, spelled wrong in record) was administered. At 3:05 AM patient was pronounced by, (physician's name). Pt's brother called no answer."

Interview with the Nursing Home Administrator and Director of Nursing on June 14, 2022, at approximately 11:00 AM revealed he was unable to state which staff members had provided CPR to Resident CR1 or if the AED was utilized as there was limited information in the clinical record. However the NHA stated that he was informed that new AED pads needed to be ordered.

The DON stated during interview on June 14, 2022, that facility would not document employee names in the resident's clinical record. However, the clinical record documentation did not identify individuals by title (RN, LPN, nurse aide) or any other means to accurately record sequence of events surrounding the staff's resuscitation efforts and staff's emergency response. The DON was was also unaware of the staff members who had provided CPR to Resident CR1.

Following surveyor inquiry and a review of Ambulance documentation (received via fax by the facility time stamped during the survey at June 14, 2022 at 10:04 AM) revealed that on May 31, 2022, at 2:48 AM the EMS noted that "CPR and AED performed by other." The EMS documentation noted that "AED on PT by staff, no shock advised, CPR in progress successful. Pt response: unchanged Oxygen initiated at 25 lpm. Bag valve Mask performed by other. BVM ventilations being given by staff." EMS documentation revealed that EMS took over at 2:49 AM.

Interview with the Director of Nursing on June 14, 2022 at approximately 2:00 PM confirmed Employee 3, RN failed to follow the facility's policy and procedures for emergency response and CPR documentation in the resident's clinical record.

Refer to F 678

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services

28 Pa. Code 211.5 (f)(g)(h) Clinical Records







 Plan of Correction - To be completed: 07/12/2022

1. A copy of the ambulance company's clinical record documentation labeling AED placement and correct CPR technique will be scanned into the resident's chart.
2. The nursing notes placed in our clinical record will be reviewed on a daily basis in morning meeting and addendums will be made for completeness and accuracy if necessary. Notes will be checked for completeness and accuracy.
3. Nursing staff will be educated on the importance of writing detailed and timely notes. We will define the parameters that we expect to have covered in a note and they will sign off on our clinical documentation policy.
4. An audit will be conducted on the daily reviewed notes. The audit will be conducted by the DON or designee weekly x 5 and monthly x2. Results of this audit will be submitted and discussed in QA.


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