Nursing Investigation Results -

Pennsylvania Department of Health
WILLOW TERRACE
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
WILLOW TERRACE
Inspection Results For:

There are  132 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.
WILLOW TERRACE - 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 June 24, 2022, it was determined that Willow Terrace, 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments: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(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II review for PASRR (Pre-Admission Screening and Resident Review) compliance for one of 33 clinical records reviewed (Resident R125).

Findings include:

The revised PA-PASRR-ID form (Pennsylvania Pre-Admission Screening and Resident Review (PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated March 1, 2009, lists examples of serious mental illness including mood disorder, bipolar, and depression.

The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that "nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status)."

Review of a PASRR form completed on March 29, 2013, revealed that under "Section III, Mental Health" assessment, question "Does the individual have a mental health condition or suspected mental health condition, other than dementia that may lead to chronic disability?" The response was entered "No". Further review of the form revealed that the individual has a negative screen for serious mental health illness, intellectual disability/developmental disability, or other related condition; no further evaluation (Level II) is necessary.

Review of clinical record for Resident R125 revealed a diagnosis list which indicated that the resident was diagnosed with schizophrenia (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and major depressive disorders.

Review of nursing progress notes for the month of May and June 2022 revealed that the resident exhibited behaviors such as wandering, yelling, screaming, crying, kicking the wall, agitation, aggressive behavior and exit seeking behaviors.

Interview with the Social worker, Employee E9 on June 23, 2022, at 11:40 a.m. stated that Resident R125 should have a PASRR level II, completed with the diagnosis of schizophrenia and major depressive disorders. Employee E9 stated resident's PASRR form was completed in 2013 and should have completed an updated assessment when schizophrenia and major depressive disorders was diagnosed which qualifies resident for a PASRR level II evaluation.

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

28 Pa. Code 211.12(d)(3) Nursing services

28 Pa. Code 211.16(a) Social services





 Plan of Correction - To be completed: 07/22/2022

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

R125 PASRR was updated and a level 2 evaluation was completed.

The Social Service director/designee conducted an audit of resident PASARR's to ensure diagnosis's are up to date and if necessary a level 2 review was completed.

The NHA educated the Social Service department on updating PASARR when a new diagnosis is added for the resident as well as initiating a level 2 review if necessary.

Social Service director/designee will audit residents that are identified as having a change in condition during the morning clinical meetings for new diagnosis. The Social Service director will update the PASARR if necessary. Audits will be done weekly x 4 then monthly x 3 months. Results of these audits will be submitted to the quality assurance committee to determine if any further action is needed.

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 the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to provide adequate supervision and failed to maintain an environment free of potential hazards for one resident who eloped from the facility (Resident R14). This was identified as past non-compliance.

Findings include:

Review of facility policy "Elopement Prevention dated, June 2020 revealed that "The facility strives to prevent resident/patient elopement. The facility also recognizes mobility as a strength to be supported and promoted."

Review of an undated, facility documentation "Mandatory In-service Competency Elopement" revealed that "If an alarm sounds on the fire doors, staff should ensure all residents are accounted for before disarming the alarm. Elopement present a huge safety risk and can lead to serious bodily injury."

Review of facility documentation dated February 25, 2022, revealed that Resident R14 opened the fire exit door and walked down the step to the ground floor, upon exiting the door leading to the outside a staff member redirected the resident. Resident was found outside by the staff and resident stated, "I am getting out of here, I am going home."

Interview with the Director of Nursing, Employee E2, on June 23, 2022, at 1:24 p.m. stated that the resident exited the building through the fire exit door on the fourth floor. Employee E5, nursing assistant responded to the alarm.

Interview with nursing assistant, Employee E5, on June 23, 2022, at 2:23 p.m. stated she was in another resident's room giving care when the exit door alarm sounded. She stated she opened the first door from the hallway and did not see anyone and disarmed the alarm. Employee E5 stated she went back to finish care and did not inform anyone about the alarm immediately. Employee E5 also stated once she finished providing care, she took a resident to dining room and informed the unit manager on her way to the dining room. She saw Resident R14 coming to the unit with another staff member. Employee E14 confirmed that she did not check the second door leading to the stairwell.

Interview with Director of Nursing, Employee E2, on June 24, 2022, at 11:30 a.m. stated Employee E5, should have opened first and second door to check for resident when exit door alarm sounded on February 25, 2022. Employees should not turn off the alarm until all residents in unit are accounted for. Employee E2 stated Employee E5 was counseled for not checking the stair after responding to door alarm.

This deficiency was identified as past non-compliance.

Review of facility Action plan/Follow up documentation revealed the following information.

Resident was safely returned to her unit.
Whole house checks were done to ensure all residents were present and accounted for.
Employee was educated on elopement policy and steps to take during an elopement. Whole house staff education conducted on elopement protocol and steps to take during an elopement.
Elopement drills were conducted on 3/11/22, 3/31/22 and 4/22/22and 5/27/22 and will be conducted at least quarterly. Elopement drills will be brought to QA and reviewed monthly x3 months and quarterly x 3 months.

28 Pa. Code 211.12(d)(1) Nursing services

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

28 Pa. Code 211.10(d) Resident care policies


 Plan of Correction - To be completed: 07/22/2022

Resident safely returned to her unit.
Whole house checks were done to ensure all residents were present and accounted for.

Employee was educated on elopement policy and steps to take during an elopement.

Whole house staff education conducted on elopement protocol and steps to take during an elopement.

Elopement drills were conducted on 3/11/22, 3/31/22, and 4/22/22, and 5/27/22. Elopement drills will be brought to QA and reviewed monthly x 3 months and quarterly x 3 months

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on the review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to intravenous therapy (a medical technique that delivers fluids, medications and nutrition directly into a person's vein) for two of five employee files reviewed. (Employee E8 and Employee E7)

Findings include:

A review of the facility documentation revealed that the facility had one resident (Resident 315)with intravenous therapy, who received treatment and care from the staff such as dressing changes, medication and fluid administration, site assessment and monitoring.

Review of clinical record revealed that Resident R315 was receiving intravenous fluid therapy via a PICC line (a peripherally inserted central catheter, less commonly called a percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period of time or for administration of substances that should not be done peripherally).

Physician orders for Resident R315 dated March 25, 2021 revealed that the resident required weekly PICC line dressing change, measurement of external catheter length, measurement of arm circumference and monitoring for complication with PICC line therapy.

A request for the evidence of intravenous therapy and tracheostomy care staff competencies or annual evaluations were made to the Nursing Home Administrator and Director of Nursing on June 24, 2022 at 10:50 a.m.

Review of personnel files for Employee E8, Licensed Nurse and Employee E9, Registered Nurse, revealed no documented evidence that the nursing staff competencies or annual evaluations related to intravenous therapy.

Interview with the Director of Nursing on June 24, at 1:37 p.m., confirmed that the annual nursing staff competencies or annual evaluations related to intravenous therapy was not completed for the nursing staff.

28 Pa. Code: 201.18 (b)(1) Management

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

28 Pa. Code: 201.18 (e)(2) Management

28 Pa. Code 211.2 (c) Nursing services

28 Pa. Code 211.2 (d)(1) Nursing services

28 Pa. Code 211.2 (d)(5) Nursing services




 Plan of Correction - To be completed: 07/22/2022

Employees E8 and E9 received competency training on intravenous therapy.

The DON/designee completed competency training on intravenous therapy for licensed staff.

The DON and ADON were educated by the regional nurse on annual competency training for staff.

The DON/designee will audit new hire orientation packets to ensure competencies are completed. Audits will be done weekly x 4 then monthly x 3 months. Results of these audits will be submitted to the quality assurance committee for review to determine if further action is needed.

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 observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that the residents meal tickets were accurate in accordance with the resident and their food preferences one of four dining rooms observed (5th floor).

Findings include:

Observation of the lunch meal service on 5th floor was conducted on June 21, 2022, at 12:56 p.m. These observations revealed that the lunch menu posted on the wall listed the main course as "sweet and sour pork" with the alternate available being "fried chicken." Observation of the steam table showed that these were the items being served that day.

Review of the residents meal tickets revealed that they were dated as July 12, 2022, with the listed main course being "macaroni and cheese." Employee E13 began dishing the pork onto trays, which were then placed into the service cart by Employees E10, E11, and E12. Interview with Employee, E12 at the time of the observation confirmed that residents were been distributed a meal ticket dated July 12, 2022 which was incorrect. Further observation revealed that when all but one tray was prepared, Employee E13 was told to stop serving while the correct tickets were printed.

On June 21, 2022 at 1:15 p.m. Employee E14 was observed brining new tickets to the 5th floor, Employee E14 indicated that he could not change the date, but that the lunch menu listed on the ticket was correct. Meal tickets were then distributed to the residents' trays, without the meal tickets being reviewed for accuracy. The final meal tray was prepared, and the trays were distributed to residents by Employees E10, E11 and E12.

The meal ticket was noted to have the corrected menu items printed out on all meal tickets for the day. Further review of the meal tickets revealed that they were printed double sided, with one resident on one side and another on the back. Further review of the new meal tickets revealed that were cut apart and then placed on trays, some were for the correct resident, but for breakfast or dinner, and some were for the correct lunch menu, but the wrong resident.

Observation of the lunch tray served to Resident R1 contained sweet and sour pork. Interview with Resident R1 during the lunch observation revealed that he was able to and enjoyed eating pork. Review of allergies and meal preferences for Resident R1 indicated that the meal served to him was acceptable. However, the ticket on his tray was for Resident R2, which stated "NO PORK" in bold letters.

28 Pa. Code: 211.6(b)(d) Dietary services

28 Pa. Code 211.29 (j) Resident rights.







 Plan of Correction - To be completed: 07/22/2022

The Dietary director reviewed meal tickets for each floor prior to dinner service to ensure meal tickets were correct. Meal tickets were correct for each floor.

The Dietary Director/designee educated the Dietary staff on tray ticket accuracy and reviewing meal tickets prior to meal service.

The Dietary Director/designee will conduct audits of tray tickets on each floor to ensure tray tickets have the correct date and correct meal.

Audits will be done daily x 2 weeks then monthly x 3 months. Results of these audits will be submitted to the quality assurance committee for review to determine if further action is needed.



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