Pennsylvania Department of Health
PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING
Patient Care Inspection Results

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PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING
Inspection Results For:

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PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on April 3, 2024, it was determined that Platinum Ridge Center for Rehab and Healing was not in compliance with the 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:


483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 7 residents reviewed. (Resident R1)

Findings include:

Review of facility policy "Food Allergies and Intolerances" dated 8.24.23, indicated residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s).

Review of facilities current Certified Nursing Assistant's (NA) job description indicated the purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility.

Review of the clinical record indicated that Resident R1 was admitted to the facility 3/7/24. The clinical record on admission indicated Resident R1 had multiple allergies which included cinnamon, shellfish, and sugar substitute.

Review of Resident R1's Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) dated 3/14/24, included diagnoses Ogilvie syndrome (a syndrome characterized by a clinical picture suggestive of mechanical obstruction in the absence of any demonstrable evidence of such an obstruction in the intestine), diabetes mellitus,(a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Further review of MDS, Section C: Cognitive Patterns indicated that Resident R1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15.

Review of Resident R1's plan of care, initiated 3/10/24, presented an identified focus related to a potential of nutritional problems due to multiple allergies. Interventions identified cinnamon, shellfish, and sugar substitute as specific food allergies for Resident R1.

Further review of clinical record revealed a progress note by Certified Dietary Manager (CDM) Employee E1, dated 3/28/24, at 9:43 a.m., which stated "Notified by nursing staff that resident received sugar free syrup, writer began investigation. Both AM cook and AM aide interviewed, both state (Resident R1) was served eggs, toast, and Canadian bacon as his posted menu states. AM cook stated she doubled checked his tray. Writer went to unit to look as resident's tray. Tray with his (Resident R1) meal ticket on did not have any diet products. Meal ticket present with allergy list available."

Further review of clinical record revealed another progress note by Registered Nurse Supervisor (RN) Employee E2, dated 3/28/24, at 10:38 a.m., which stated "This am at 8:05, resident (R1) stated that he was having a reaction to sugar substitute that was in the syrup he had on his pancakes for breakfast. Dr. (Medical Director) was rounding and assessed resident. He (Resident R1) was having throat swelling and difficulty breathing. EMS (Emergency Medical Services) was called. Epi pen (an autoinjector medical device for injecting a measured dose or doses of epinephrine used for the emergency treatment for severe allergic reactions) pulled from omnicell (automated system for medication management in healthcare facilities) and administered at 8:16am. Staff remained with resident until EMS arrived and took resident to ER (Emergency room). Family was notified."

Further review of clinical record revealed another progress note by Registered Nurse Supervisor (RN) Employee E2, dated 3/28/24, at 2:14 p.m., which stated "Resident (R1) returned from ER. NNO (no new orders)."

Review of Resident R1's Dietary ticket titled, Thursday, 3/28/24, indicated Resident R1 Allergies: artificial sweetener, cinnamon, and shellfish; Note: No iced tea, diet ginger ale, flavored water, or diet cola, check all desserts, cereal, and snacks for cinnamon and sugar substitutes. Diet order on Dietary ticket indicated Resident R1 was on a Regular, no Restriction diet.

Review of facility provided investigation documents, dated 3/29/24, indicated that on 3/28/24, resident (R1) received eggs, toast and Canadian bacon on his breakfast tray. He (Resident R1) asked the NA on duty (NA Employee E3) for something different. Resident (R1) is alert and oriented with a BIMS score of 15. The NA called the dietary department and ordered him (Resident R1) pancakes. She (NA Employee E3) did not identify which resident the pancakes were for when calling dietary. The pancakes were delivered to the unit and the NA (Employee E3) put a packet of sugar free syrup on the tray and took it to his (Resident R1) room. As he (Resident R1) was eating, (Resident R1) put on his call bell and alerted staff that he felt though his throat was closing up and he was having difficulty breathing. It was determined that he (Resident R1) has an allergy to the sugar substitute in the sugar free syrup. Resident (R1) allergies were listed on the dietary slip sent up on original breakfast tray as well as in the EMR (electronic medical record).

Interview conducted on 4/3/24, at 2:30 p.m., Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to ensure residents were provided food that accommodates resident's allergies for one of 7 residents reviewed. (Resident R1)

Pa Code: 211.6(a) Dietary services







 Plan of Correction - To be completed: 05/01/2024

F806 - The facility shall ensure residents are provided food that accommodate their allergies.

Resident R1 was successfully treated with epinephrine prior to transfer to the hospital. No further interventions were necessary. Resident was deemed capable and stable enough to follow through with planned discharge to home that day.

All residents were assessed to ensure accuracy of food allergies. Residents admitted to the facility will have a dietary consultation completed upon admission and food allergies noted. Resident meal tickets were reviewed by the Food Service Director, or designee, for accuracy related to any food allergies.

The facility Director of Nursing, or designee, will review the resident's record upon admission, during clinical start up, for possible food allergies. The facility Food Service Director, or designee, shall review newly admitted resident meal ticket for accuracy related to any food allergies.

Education shall be provided to the nursing staff and dietary personnel by the facility Director of Nursing, or designee, on F806 requirements, with a focus on accommodating any resident food allergies and ensuring their diet is compliant for any food allergies.

The facility Director of Nursing, or designee, shall audit newly admitted residents for food allergies three times a week for two weeks, two times a week for two weeks, and once a week for two weeks. The facility Food Service Director, or designee, shall audit the residents' meal ticket and tray for any resident food allergies three times a week for two weeks, two times a week for two weeks, and once a week for two weeks.

The facility Administrator shall ensure compliance.




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