Nursing Investigation Results -

Pennsylvania Department of Health
GLEN AT WILLOW VALLEY, THE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GLEN AT WILLOW VALLEY, THE
Inspection Results For:

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GLEN AT WILLOW VALLEY, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure and Civil Rights Compliance survey completed on December 2, 2021, it was determined that The Glen at Willow Valley 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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, review of facility documentation and interview, it was determined that the facility failed to provide supervision to prevent a second fall resulting in actual harm of a identified probable nasal fracture to one of eight residents reviewed (Resident 53). This was identified as past non compliance effective September 30, 2021.

Findings include:

Review of facility policies and procedures failed to reveal a policy identifying when additonal supervision is warranted for outside appointments or activities.

Review of Resident 53's diagnosis list revealed diagnoses including vascular dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality, contact and functioning ability).

Review of Resident 53's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 13, 2021 revealed Resident 53's Brief Interview for Mental Status Score indicated severe cognitive impairment. Further review of Resident 53's Quarterly MDS revealed Resident 53 required the extensive assistance of one staff member to transfer in and out of a wheelchair.

Review of Resident 53's current care plan revealed Resident 53 is at risk for falls related to a history of falls and to remind resident to request transfer assistance from staff.

Review of Resident 53's Morse Fall Scale dated August 24, 2021 revealed a score of 80 indicating Resident 53 had a high probable risk for falls.

Review of Resident 53's progress notes dated August 26, 2021 revealed "aide alerted nurse resident had fallen. Resident was just given pain med at 1353 [1:53 p.m.] . Resident was sitting in assist dining room in w/c [wheelchair]. W/c was locked. Resident had gotten up with w/c locked and fallen near table. Resident incontinent of bladder. Resident with abrasion to L [left] side of face and lump noted to L forehead. Resident confused and impulsive."

Further review of Resident 53's progress notes dated August 27, 2021 revealed "went to assess resident and noted facial swelling around bilateral orbits [around eyes] with ecchymosis [bruising]. Neuro checks have been stable with VS [vital signs]. [physician] notified of my concerns for possible orbital [bones around eyes] fractures. Order received to send resident out for CT scan of head and face w/o [without] contrast. All required information faxed to CT scan office. LMSA [area emergency transportation company] notified and time will be 04:30 [4:30 p.m.] Daughter called and message left. Resident is stable at present. No c/o [complaints of] pain."

Further review of Resident 53's progress notes dated August 27, 2021 revealed "it was reported that on 8/27/21 at 1907 pm [7:07 p.m.] the evening supervisor received a call from [hospital] ER [emergency room] [nurse] saying that the resident had fallen at the [hospital] outpatient pavilion after a CT scan and was transferred to the ER for an evaluation."

Further review of Resident 53's progress notes dated August 28, 2021 revealed "received in report at change of shift that resident was in [hospital] and would most likely be returning. At 23:30 [11:30 p.m.] on 8/27/21 spoke with [nurse at hospital]. She reported that the resident would be returning. The nurse reported that the resident had gone for a CT scan of her head and it indicated a left frontal and orbital fracture, along with a left hematoma. Prior to returning, the resident had a fall and she was brought back to [hospital] to have another CT scan done. The 2nd CT scan indicated a possible nasal fracture. This was in addition to the first CT scan. The resident arrived at 12:30 a.m. on 8/28/21. Her VSS [vital signs stable], she had no c/o pain/discomfort. Her b/l [bilateral - both sides] eyes are both bruised with the left eye closed over. She is resting comfortably at this time."

Review of Employee E4's witness statement dated August 31, 2021 revealed that Employee E4 received a telephone call from Licensed RN Employee E3 and Licensed RN Employee E5 requesting information on scheduling a CT scan. Employee E4 supplied the requested information and offered to arrange transportation for Resident 53. Employee E4 subsequently arranged for transportation for Resident 53 to the hospital for the CT Scan.

Interview with Employee E4 on December 2, 2021 at 9:50 a.m. revealed that Employee E4 set up transportation for Resident 53. The interview further revealed that Employee E4 did not obtain a staff person to accompany resident 53 to the hospital for the CT Scan. The interview further revealed that Employee E4 would normally ask the clinical manager if the resident needs assistance at the appointment, however Employee E4 was unfamiliar with Resident 53 because Resident 53 was not a resident on the unit where Employee E4 worked. Employee E4 was assisting Licensed Employee E5, clinical manager on Resident 53's nursing unit. Employee E4 also stated that employee was not informed that Resident 53 would need a staff person to accompany the resident to the appointment.

Review of Licensed Employee E3's witness statement dated August 31, 2021 revealed that Licensed Employee E3 received a phone call from Licensed Employee E5 requesting assistance to schedule a CT Scan for Resident 53. Licensed Employee E3 called Employee E4 for assistance.

Interview with Licensed RN Employee E3 on December 2, 2021 at 10:02 a.m. revealed Licensed RN Employee E3 received a telephone call from Licensed Employee E5 requesting assistance with scheduling a CT Scan. Licensed Employee E3 contacted Employee E4 to assist Licensed Employee E5. Licensed Employee E3 did not obtain a staff person to accompany Resident 53 to the hospital for the CT Scan. The interview further revealed that assigning staff persons to accompany residents to appointments is a clinical judgment by the clinical managers to determine if the resident requires someone to accompany them.

Review of Licensed Employee E5's witness statement dated August 31, 2021 revealed Licensed Employee E5 asked Licensed Employee E3 how to make arrangements for a CT scan for Resident 53. Licensed Employee E3 and Licensed Employee E5 were unsure how to set up transportation and called Employee E4 for assistance. Licensed Employee E5 prepared Resident 53 for transport and obtained the appropriate paperwork. Licensed Employee E5 spoke with the transportation driver regarding Resident 53's recent fall and the transportation driver would be taking resident directly into the CT scan department. Licensed Employee E5's witness statement revealed "I thought he was going to stay with her since it was such a short procedure."

Licensed Employee E5 no longer works at the facility, therefore an interview of Licensed Employee E5 was not able to be obtained.

Review of Resident 53's CT scan of facial bones results dated August 27, 2021 at 5:08 p.m. revealed "Left orbital floor fracture without entrapment. The nasal bone is intact."

Review of Resident 53's CT scan of facial bones result dated August 27, 2021 at 9:01 p.m. revealed "Again noted is a mildly depressed orbital floor fracture. There are probable nasal fractures."

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 2, 2021 at approximately 11:00 a.m.

The facility failed to provide supervision for a resident with history of falls, severe cognitive impairment, high probable fall risk, extensive staff assistance, and recent fall; during an outside diagnostic appointment, resulting in Resident 53 falling from the wheelchair and requiring a second CT Scan with a result of probable nasal fractures resulting in actual harm to Resident 53.

Pa. Code 210.18(b)(1) Management





















 Plan of Correction - To be completed: 11/29/2021

"Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice, administrative proceedings or other court proceedings."

1.On August 27, 2021 Resident #53 was transported to the Hospital's Outpatient facility for a CT of the head accompanied by a Medical Transport employee. Upon arrival Resident #53 was received for care and services and accepted by the Outpatient facility staff for a scheduled CT. Upon further facility investigation, interview with the Hospital/Outpatient Director of Diagnostic Imaging, Resident #53's fall post procedure occurred in a small sub-waiting room. This small waiting room is monitored by the Outpatient team and is under surveillance by a camera. Resident #53 will have supervision with any scheduled out of facility appointments. Care Plan for Falls was updated on 8/31/2021.
2. No other Residents were affected by this practice. The facilities transportation protocol for setting up transportation as needed for companionship/supervision is based on the resident's individual needs and appointment location guidelines.
3. Upon hire, Unit Clerks are educated on facility processes for transportation and supervision of Residents. On 9/3/21 a review of the transportation process was completed by facility Unit Clerks. In addition, Nursing Team Members were educated on the facility transportation process.
4.The facility Administrator/Designee completed a Resident Transportation with Supervision Audit. The audits were completed for five consecutive weeks from August 30th, 2021 through October 1, 2021. All audits continued to show compliance with supervision with no further action required. Findings of these audits will be reported to the 4th Quarter Quality Assurance Committee Meeting.
5. Date of completed corrective action was 9/3/21.


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