Nursing Investigation Results -

Pennsylvania Department of Health
GREENLEAF NSG & CONV CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREENLEAF NSG & CONV CENTER
Inspection Results For:

There are  70 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GREENLEAF NSG & CONV CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey and Civil Rights Compliance survey completed on September 20, 2019, it was determined that Greenleaf Nursing and Convalescent Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care 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 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.
Observations:

Based on clinical record review and review of incident reports, it was determined that the facility failed to provide adequate supervision in order to prevent falls for one of three sampled residents at risk for falls. (Resident 56)

Findings include:

Clinical record review revealed that Resident 56 had diagnoses that included psychosis, delusional disorders, anxiety and dementia. The Minimum Data Set assessment dated May 8, 2019, indicated that the resident had memory impairment, required extensive assistance from staff for transfers and bed mobility, used a wheelchair, and was not steady moving from a seated to a standing position. The assessment also indicated that the resident had a history of falls. The current care plan identified that the resdient was at risk for falls due to being unaware of safety needs. Review of an incident report dated August 21, 2019, at 5:15 a.m., revealed the the resident was found on the floor in front of her wheelchair inside of a different resident's room. The incident report indicated that the resident had been awake all night, she had refused to go to bed and had been wandering and restless in the hallway. Review of a nursing note dated August 31, 2019, at 1:28 a.m., revealed that the resident was up out of bed in her wheelchair propelling around the halls. The note further indicated that the resident had gotten up out of her wheelchair and was walking in the halls three times and was restless. The resident had refused to go to bed. Review of an incident report the next day, September 1, 2019, at 1:15 a.m., revealed that the resident had attempted to get out of bed and fell in her room. The resident was transferred to the hospital after the fall. Review of an incident report dated September 10, 2019, at 11:00 p.m., revealed that the resident was noted to be "scooting on her buttocks in the hallway outside of her room." The incident report indicated that the resident had been restless prior to being discovered on the floor. Review of an incident report on September 12, 2019, at 3:30 a.m., revealed that the staff heard a loud noise and found the resident on the floor beside her closet door holding the back of her head. The incident report indicated that the resident had been wandering and was restless prior to being found on the floor. The facility failed to provide a resident who experienced four falls on the 11:00 p.m. to 7:00 a.m., shift between August 21 through September 12, 2019, adequate supervision in order to prevent falls.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 10/18/18




 Plan of Correction - To be completed: 10/10/2019

0689


1. On day of survey Resident #56 was placed on Q1hr checks on the (11-7) shift and will remain in a supervised area during waking hours as tolerated. Care Plans and interventions have been updated to ensure Resident #56 receives adequate supervision to aid in fall prevention.

2. All incident reports pertaining to falls, reported 30 days prior to the survey were reviewed. The Care Plans and interventions have been updated as necessary to ensure each resident receives adequate supervision and assistance devices to prevent accidents.

3. All resident falls will be tracked daily to identify frequency and trends. Care Plans and interventions will be put into place to ensure each resident receives adequate supervision and assistance devices to prevent accidents.

4. A Falls Audit will be completed monthly x 3 months and then quarterly thereafter to monitor and track trends, frequency, location and shifts. All results will be reported to QAPI Committee to ensure the solutions are sustained.





Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port