Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT AT GRANITE FARMS ESTATES
Patient Care Inspection Results

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WILLOWBROOKE COURT AT GRANITE FARMS ESTATES
Inspection Results For:

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WILLOWBROOKE COURT AT GRANITE FARMS ESTATES - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey and State Licensure, Civil Rights Compliance Survey, and a complaint survey, completed on June 24, 2022, it was determined that Willowbrooke Court- Granite Farms was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.





































































 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on clinical record review, staff interview and policy and procedure review it as determined the facility failed to notify the physician of a change in resident's status for one of 24 residents reviewed. (Resident 43)

Findings Include:

Review of facility policy and procedure titled Physician Notification, revised June 2014, revealed the licensed nurse is responsible for notifying the resident's physician at a minimum when there is: a significant change in the resident's physical, mental or psychosocial status. A need to significantly alter treatment. A decision to transfer or discharge the resident from the community. Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident.

Review of resident 43's progress notes revealed a nursing entry dated May 27, 2022 at 7:41 a.m. stating resident noted with slight nose bleed. MD (Medical Doctor) was notified and ordered to hold Coumadin (blood thinner) tonight and to continue with weekly labs for PT/INR (blood test to determine the effectiveness of Coumadin).

Review of progress note dated May 28, 2022 at 11:51 a.m. stated at 9:00 a.m. CNA (certified nurse aide) "summoned this nurse to the resident's room, arrived to find resident with active nose bleed." Resident stated it started as soon as he got out of bed. MD gave order to hold todays Plavix (blood thinner) and to hold tonight's Coumadin dose and obtain a stat PT/INR in a.m. and call MD with results.

Further review of the resident clinical record including Progress Notes revealed a nursing entry on May 28, 2022 at 8:39 p.m. stating resident had a nose bleed after dinner this evening. This nurse used a tampon to help with stopping bleeding and it worked.

Review of the clinical record revealed the PT/INR (blood test to determine the effectiveness of Coumadin a blood thinner) was completed on May 29, 2022 and was a high result of 30.8/3.34 indicating the resident blood is too thin. A progress note dated May 29, 2022 at 10:13 revealed the MD was notified and they were awaiting a call back.

Review of resident's Progress note dated May 29, 2022 at 11:57 p.m. stated, "resident complained of right leg and thigh pain. Will pass on to oncoming nurse to follow-up with complaint in the morning."

Review of progress notes dated May 30, 2022 at 7:19 a.m. revealed the "resident complained of pain of right thigh. Repositioning in bed did not relieve pain. Message left for on call clinician regarding pain. Oncoming shift made aware to follow up."

Review of progress notes dated May 30, 2022 at 3:15 p.m. revealed the resident complained of right thigh/buttock pain. As needed Tylenol was administered due to pain intolerance. This note made no mention of talking to a physician.

Review of progress notes dated May 30, 2022 at 7:38 p.m. revealed the resident's daughter came to the nursing station saying Resident 43's leg pain had increased. The pain was now in the right groin. Resident stated the pain was a 10 on the pain scale (most intense pain), and was unable to straighten his leg. Daughter and resident informed that resident should be evaluated in the ER and resident agreed. Resident sent via EMT at 6:30 p.m."

Review of progress note dated May 31, 2022 at 1:43 a.m. stated "off going nurse informed this nurse that resident was admitted to the hospital with a diagnosis of hematoma to the right iliopsoas (bruise of the hip muscle that is a complication that occurs in patients receiving anticoagulant therapy)."

Interview with the Nursing Home Administrator on June 24, 2022 at approximately 11:00 a.m. confirmed there was documented evidence the resident physician had never been notified after Resident 43 had the second nosebleed or with the elevated PT/INR result obtained on May 29th, 2022 or when the resident developed leg pain unrelieved by medications.

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

28 Pa. Code 211.5(f) Clinical records

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







 Plan of Correction - To be completed: 08/05/2022

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.


Resident #43: Medical Director notified and updated regarding resident status.

An audit will be conducted by the Director of Nursing/designee to verify any resident who experienced changes was communicated timely to the physician.

Director of Nursing/designee will re-inservice the licensed nurses on the Physician Notification Policy and Procedure.

Director of Nursing/designee to conduct chart audits of those residents identified during 24 hour report/daily team meetings with any changes to verify timely notification of physician daily x two weeks, weekly x one month and then monthly x 3 months with the results to be reported at our QAPI meeting monthly for five months and as needed.


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 14 residents reviewed (Resident 22).

Findings include:

Review of the facility's policy titled "Incident Reporting/Injury Investigation Residents and Visitors", undated, revealed all staff shall be responsible for promptly reporting all injuries/incidents to the charge nurse on duty. Upon receipt of a report of incident/injury, the charge nurse or supervisor shall immediately evaluate the resident, provide any needed intervention, and complete all areas of the Incident Investigation Form. The same policy indicated that if the incident is of unknown etiology and further investigation is needed for any incident including unwitnessed falls, staff on the three shifts over the 24 hours preceding the incident will be interviewed and will complete written statements concerning their observation of the incident.

Review of Resident 22's diagnosis revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severe enough to interfere with daily life).

Review of Resident 22's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 4, 2022, revealed resident had severe cognitive impairment.

Review of the progress notes dated May 24, 2022, revealed Resident 22 was with confusion and need redirecting at the time. The same note revealed resident was able to self-propel a wheelchair and required moderate assistance with ADLs (activity of daily living).

Observation conducted on June 22, 2022, at 11:00 a.m., revealed Resident 22 with a bruise on his/her right forearm, close observation of the bruise revealed the bruise was above the wrist to forearm, dark purple in the inner part of the arm extending to the outer part of the arm.

Interview with licensed nurse, Employee E3 conducted on June 22, 2022, at 11:10 a.m., Employee E3 reported that she/he was not a regular employee of the facility but was familiar with Resident 22's care. Employee E3 reported that she/he worked on the morning of June 21, 2022, and observed Resident 22's bruise on the right arm but does not know how it happened. Employee 3 looked at the resident's bruise, left then came back to inform the surveyor that she was informed by other staff that the resident had a fall over the weekend.

Observation conducted on June 24, 2022, at 10:30 a.m., with the presence of licensed nurse Employee E4. Resident 22's right arm bruise was measured by Employee E4 and revealed 12 x 11 cm (centimeter) in size, the color remained dark purple from the inner arm extending to the outer arm.

Interview with licensed Employee 4 conducted on June 24, 2022, at 10:30 a.m., revealed no knowledge of the bruise and its origin.

Interview with the Director of Nursing (DON) on June 24, 2022, at 11:00 a.m., was conducted. The facility failed to provide documented evidence the bruise on Resident 22's right arm was investigated upon discovery. The DON confirmed that Resident 22's right arm bruise was not investigated.

The facility failed to investigate Resident 22's right arm bruise.

28 Pa. Code 201.18(b)(1) Management
Previously cited 5/27/21

28 Pa. Code 211.5(f) Clinical records
Previously cited 5/27/21

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 5/27/21

28 Pa. Code 211.10(c) Resident care policies






 Plan of Correction - To be completed: 08/05/2022

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

Resident #22- Investigation and documentation has been completed as per policy.

An audit will be conducted by Director of Nursing/designee of incident reports related to injury of unknown origin within the last 30 days to verify a thorough investigation was completed.

Director of Nursing/designee will
re-inservice licensed nurses on the Incident Reporting/Injury Investigation Resident/Visitor Policy and Procedure.

Director of Nursing/designee will conduct audits of injury of unknown etiology incident reports to verify documentation is complete. This will be completed weekly x one month and monthly x 3 months with the results of these audits to be reported to the QAPI Committee monthly for four months and as needed.


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 clinical records review and staff interview, it was determined that the facility failed to follow a physician's order regarding medication administration for two of 14 residents reviewed (Resident 22, and 44).

Findings include:

Review of Resident 22's diagnosis list revealed Congestive Heart Failure, and Hypertension (elevated blood pressure).

Review of Resident 22's Physician's Order (POS) dated May 2, 2022, revealed an order for Amlodipine (medication used to treat high blood pressure) 10 mg (milligram) give one tablet by mouth one time a day. The same order had administration parameter order to hold the medications for SBP (systolic blood pressure) less than 110.

Review of Resident 22's May 2022, Medication Administration record (MAR) revealed Resident 22 was administered Amlodipine 27 times without a blood pressure parameter noted.

Interview with the Nursing Home Administrator (NHA)was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 22's blood pressure was checked before administration of Amlodipine. The NHA confirmed the lack of documented evidence that Resident 22's physician's order to administer Amlodipine with blood pressure parameter was followed.

Review of Resident 36's diagnosis list revealed Atrial Fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and Thrombosis on the right femoral vein (blood clot on the large blood vessel in the thigh).

Review of Resident 36's POS revealed an order on June 4, 2022, for Apixaban (medication used to treat and prevent blood clots and prevent stroke) tablet 5 mg, give one tablet by mouth two times a day for DVT (Deep Vein Thrombosis) prophylaxis.

Review of Resident 36's June 2022, MAR revealed Apixaban was not administered on the morning of June 9, and on the evening of June 11, and 12, 2022.

Interview with the Nursing Home Administrator on June 24, 2022, at 10:00 a.m., was conducted. The NHA was unable to provide explanation as to why Resident 36's Apixaban was not administered on the dates mentioned above.

Review of Resident 36's POS revealed an order on May 25, 2022, for a Midodrine HCL tablet (medication to treat a kind of low blood pressure that causes severe dizziness and fainting) 2.5 mg. Give one tablet by mouth in the morning for hypotension (low blood pressure) and hold for SBP (Systolic Blood Pressure) greater than 140.

Review of Resident 36's May 2022, MAR revealed Midodrine was administered to the resident seven times without a blood pressure parameter noted.

Interview with the Nursing Home Administrator was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 36's blood pressure was checked prior to the administration of Midodrine. The NHA confirmed that there was no documented evidence that Resident 36's physician's order to administer Midodrine with blood pressure parameter was followed.

The facility failed to follow the physician's medications order for Resident 22, and 36.

28 Pa. Code 211.5(f) Clinical records
Previously cited 5/27/21

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 5/27/21






 Plan of Correction - To be completed: 08/05/2022

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

Residents #22 and #36: Physician orders have been reviewed and clarified.
Appropriate documentation is in place for the completion and documentation of parameters prior to medication administration as per physician orders.

Resident #36: Resident's physician notified of medication omissions.

Director of Nursing/designee to re-inservice licensed nurses on Medication Administration Standards and Documentation Policy and Procedure.

Current resident medication administration sheets (MARS) have been reviewed by the Director of Nursing for completion including medications requiring parameters to verify that the supplemental documentation was completed prior to administering medication.

Director of Nursing/designee will complete audits of Medication Administration Sheets (MARS) to verify complete and accurate documentation weekly x one month and monthly x 3 months. Results to be reported at the QAPI meetings monthly for four months and as needed.

483.50(a)(1)(iv) REQUIREMENT Lab Services Not Provided On-Site: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.
483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(iv) If the facility does not provide laboratory services on site, it must have an agreement to obtain these services from a laboratory that meets the applicable requirements of part 493 of this chapter.
Observations:

Based on clinical record review and staff interview it was determined the facility failed to complete laboratory studies as ordered by the physician for one of one residents reviewed. (Resident 43)

Findings Include:

Review of Resident 43's physician orders revealed an order dated May 17, 2022 for a PT/INR (blood test to determine the effectiveness of Coumadin a blood thinner) to be completed every Tuesday.

Review of Resident 43's Medication Administration record revealed the lab study was documented as being completed on May 24, 2022.

The facility was asked to provide the results of the PT/INR test but were unable to produce evidence the test was completed.

Interview with the physician who ordered the laboratory study on June 24, 2022 at 1:00 p.m. confirmed after checking with the laboratory that the study had not been completed as ordered.

20 Pa Code 211.2 Physician services

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




 Plan of Correction - To be completed: 08/05/2022

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

Resident #43: Lab study (PT/INR) was completed on 5/29/22.

An audit will be conducted by Director of Nursing/designee of laboratory studies for the month of June 2022 to verify completion as physician ordered.

Director of Nursing/designee to re-inservice licensed nurses on the proper procedure regarding the ordering and follow through of laboratory studies to include the daily chart check process.

Director of Nursing/designee to conduct audits of laboratory studies identified by the order recap report to verify completion as ordered by the physician daily x two weeks, weekly x one month and then monthly x 3 months. Results to be reported at our QAPI Committee meeting monthly for five months and as needed.


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