Pennsylvania Department of Health
WILLOW TERRACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WILLOW TERRACE
Inspection Results For:

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WILLOW TERRACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an unannounced abbreviated survey in response to four complaints completed on May 31, 2024, it was determined Willow Terrace was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirement for Long Term Care F and 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical record and interview with staff, it was determined that the facility failed to inform residents of tests results and the facility failed to follow-up on the result of test results resulting in a delay in providing resident of the test results for one of seven residents reviewed (Resident R1)

Findings include:

Review of Resident R1's annual MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) dated April 3, 2024, section C0500 BIMS (brief interview for mental status) revealed that Resident R1 scored 15 suggesting that Resident R1 was cognitively intact.

Review of resident diagnoses list revealed that resident had diagnoses of but not limited to Diabetes Mellitus (a group of diseases that result in too much sugar in the blood), Anxiety Disorder, Depression

Further review of Resident R1's clinical record revealed that a test for Hemoglobin A1C (HbA1C-a blood test that shows the average blood sugar during the past two to three months) was done on February 6, 2024. Further review of Resident R1's clinical record revealed that a test result dated February 6, 2024, indicated "test previously reported". Further, there were no values indicated on the results.

Further review of Resident R1's clinical record revealed no documentation regarding the result of the A1C, there was documented evidence that clinical staff followed up on the result and no documented evidence that Resident R1 was made aware of the result.

Interview with the DON (Director of Nursing) Employee E2 revealed that the Hemoglobin A1C finding indicating "test previously reported" probably means that somebody from the laboratory probably called someone in the facility and that someone in the facility received the results but that the person who received the result did not document it in Resident R1's clinical record. Employee E2 also revealed that if someone received the result from the laboratory, the results should have been documented in Resident R1's clinical record.

Review of physician note date May 29, 2024 revealed that CT (computed tomography-is a medical imaging technique used to obtain detailed internal images of the body) scan shows nodules. Further, there was a recommendation to see pulmonary.

Further interview with Employee E2 revealed that CT scan was done a few weeks ago to rule out lung mass and that the results was just faxed to facility on May 29, 2024. Further, Employee E2 confirmed that the facility did not follow-up on the result of the CT scan until May 29, 2024.

Further interview with Employee E 2 revealed that the CT scan findings shows nodule, and that the facility physician will speak with resident.

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

Plan of Correction - To be completed: 07/08/2024

This provider submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

R1 was made aware of the HBA1C results as well as the Cat Scan results.
The DON/designee conducted a 1 week look back of ordered labs and outpatient diagnostic studies to ensure that the resident or resident representative were made aware of the results.
Licensed staff were educated by the DON/designee on timely follow up of lab results and outpatient diagnostic tests as well as notifying the resident or resident representative of the results.
The DON/designee will audit ordered labs and diagnostic test to ensure results were received, and that the resident/resident representative were made aware of the results. Audits will be done weekly x 4 weeks and then monthly x 2 months.
Results of the audits will be submitted to the Quality Assurance Committee to determine if further action is needed.

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