Pennsylvania Department of Health
HEMPFIELD MANOR
Patient Care Inspection Results

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HEMPFIELD MANOR
Inspection Results For:

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HEMPFIELD MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to two complaints completed on April 2, 2024, it was determined that Hempfield Manor, 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.


 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1).

Findings include:

Review of facility policy "Pressure Ulcer Policy" dated 12/13/23, indicated a resident who enters the facility without a pressure ulcer will not develop a pressure ulcer unless the individual's clinical condition demonstrates they are unavoidable. All residents will be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/30/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/24, indicated diagnoses of high blood pressure, diabetes (high blood sugar levels), and anemia (too little iron in the blood). Section M: Skin Conditions, Question M0150 indicated Resident R1 had no unhealed pressure ulcers/injuries present on admission to the facility.

Review of Resident R1's Nursing Admission/Readmission Screener dated 1/30/24, indicated Resident R1 had shearing/incontinent dermatitis (inflammation of the skin) on the coccyx (center mid-buttocks region).

Review of a physician order dated 2/2/24, indicated to apply Medihoney (a wound gel) to bilateral buttocks wounds topically every day and every evening shift and cover with border gauze (a self-adhering, multi-layer foam dressing).

Review of a Nursing Weekly Skin and Body Review dated 2/6/24, indicated no new skin abnormalities were identified.

Review of a Nursing Weekly Skin and Body Review dated 2/13/24, indicated no new skin abnormalities were identified.

Review of a Skin/Wound Note dated 2/14/24, indicated Resident R1 had a Stage II Pressure Ulcer (partial thickness skin loss involving epidermis, dermis, or both) present on her buttocks, measuring 1.3 centimeters (cm) Length (L) x 1.3 cm Width (W) x 0.1 cm Depth (D). The wound had a status of not healed.

Review of a Skin/Wound Note dated 2/21/24, indicated Resident R1's Stage 2 Pressure Ulcer to her buttocks measured L 4.4 cm x W 3.6 cm x D 0.1 cm. The wound had a status of not healed and that the wound was deteriorating.

Review of Resident R1's Treatment Administration Record (TAR) dated February 2024, failed to reveal documentation to indicate that the dressing change to Resident R1's buttocks occurred on 2/12/24, during the day shift, 2/17/24, on the day and evening shifts, 2/18/24, on the evening shift, and 2/1924, on the day shift.

During an interview on 4/2/24, at 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1).

28 Pa. Code:211.10(a)(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/13/2024

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Hempfield Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Hempfield Manor credible allegation of compliance.
Resident R1 was discharged from the facility on 2/22/24. The DON or designee will assess all current residents for pressure risk and a skin assessment will be completed by 4/24/24 to ensure any skin breakdown is documented and treated via wound care protocols. Skin assessments are completed on all residents upon initial admission or readmission from hospital, all residents are monitored weekly via skin assessments, and reviewed quarterly or at any significant change. The residents identified as having skin pressure ulcers are seen by either the contracted wound nurse practitioner weekly or go out to a wound clinic per residents choice. The DON or designee will conduct inservice education to all licensed nursing staff at the April 2024 nurse staff meetings on consistency and accuracy in skin assessments and documentation requirements, including careplanning and accuracy of wound treatment ordered. The ADON or designee will conduct inservice education to all certified nursing assistants at the April 2024 nurse aide staff meetings on protocols when a reddened or pressure area is observed during care. Hempfield Manor will monitor for corrective action via auditing new admissions for initial skin assessments, weekly skin assessments for current residents, treatment orders for wound care, and updated wound careplans . The ADON or designee will complete audits weekly for one month, monthly for three months, and quarterly thereafter. Results of audits will be reviewed at quarterly QAPI meetings.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on seven of 21 days (3/17/24, 3/24/24, 3/28/24, 3/29/24, 3/30/24, 3/31/24, and 4/1/24).

Findings include:

Nursing time schedules for the time frame 3/13/24, through 4/2/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24-hour period on the following dates:

3/17/24 - 2.68
3/24/24 - 2.80
3/28/24 - 2.78
3/29/24 - 2.56
3/30/24 - 2.85
3/31/24 - 2.58
4/1/24 - 2.66

During an interview with on 4/2/24, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on seven of 21 days as required.


 Plan of Correction - To be completed: 05/13/2024

All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident.
Residents of Hempfield Manor will be protected from future staff ratios below 2.87 by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily to ensure that any foreseeable staffing levels below 2.87 PPD are adequately covered. Weekend and Shift Supervisors will immediately contact DON/ADON for any day that ratios unexpectedly drop below the 2.87 minimum for immediate resolution.
Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio minimum levels. Hempfield Manor has raised all wages for licensed and certified nursing staff. Hempfield Manor has instituted a Hiring Bonus payment for RN/LPN applicants specific to 11-7, night time shift and for C.N.A applicants specific to the 3-11 shift. Hempfield Manor also offers extra payment incentives to current staff to cover extra shifts. As a QA audit, staffing ratios will be reviewed by the DON/nursing designee 3 times a week for a month, then weekly for 3 weeks then monthly for 2 months until compliance is achieved. Results will be reported on a monthly basis during the monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.


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