Nursing Investigation Results -

Pennsylvania Department of Health
HARMON HOUSE CARE CENTER
Patient Care Inspection Results

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HARMON HOUSE CARE CENTER
Inspection Results For:

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HARMON HOUSE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an incident survey completed on February 14, 2020, it was determined that Harmon House Care Center 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(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 review of policies, manufacturer's instructions, residents' clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to complete an air mattress safety assessment to identify potential safety hazards for one of 17 residents reviewed (Resident 1).

Findings include:

The facility's policy regarding specialty mattress utilization, dated August 1, 2019, indicated that to facilitate wound healing, the facility would utilize a specialty mattress for any resident deemed clinically appropriate, with no contraindications. If a resident required a specialty mattress and had no contraindications, a physician's order would be obtained. The contraindications included a low electric bed, high risk for falls, and no bed assistive devices. If a contraindication was present, the interdisciplinary team, including the physician and resident representative, would determine risks versus benefits for the use of the mattress. After the initiation of the air mattress, the nursing department was to check the mattress for efficiency according to the manufacturer's instructions.

Undated manufacturer's instructions for an air mattress used by Resident 1 indicated that staff were to check to see if a suitable pressure was selected by sliding one hand between the air mattress and the foam base to feel the patient's buttock. Users should be able to feel the space in between, and the acceptable range was approximately twenty-five to forty millimeters (1"-1.5"). It was recommended that the pressure selector knob be set to firm or press autofirm on the touch panel every time the mattress was first inflated. Users could then easily adjust the air mattress to a desired firmness according to the resident's weight.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 5, 2019, revealed that the resident required extensive assistance with bed mobility and was 69 inches tall and weighed 237 pounds. A nursing note, dated February 7, 2020, revealed that Resident 1 was re-admitted to the facility from the hospital, and a baseline care plan, dated February 7, 2020, indicated that the resident had a history of falls, required the assistance of one staff with bed mobility, and did not have an air mattress on his bed.

A nursing note for Resident 1, dated February 10, 2020, at 6:45 a.m. indicated that the resident had a history of falls and had a fall score that indicated he was at high risk for falls.

Facility investigation documents, dated February 10, 2020, at 6:45 a.m. revealed that Nurse Aide 1 went to change Resident 1's sheets and when she rolled him away from her, his lower body slipped out of the bed and she then lowered the rest of his body onto the fall mat. The resident was left face down on the fall mat while Nurse Aide 1 left the room to get help. When the resident was rolled onto his back, his face was purple in color. He took a deep breath and then a second deep breath after which he stopped breathing.

Observations on February 11, 2020, at 4:42 p.m. revealed that Resident 1's bed was equipped with an air mattress.

There was no documented evidence that a physician's order was obtained for the use of an air mattress for Resident 1 and no documented evidence that an assessment was completed to identify any potential safety hazards caused by the use of an air mattress for Resident 1. There was also no documented evidence that settings for the air mattress were determined or available to staff and no documented evidence that staff checked the function and settings of Resident 1's air mattress.

Interview with the Director of Nursing on February 7, 2020, at 6:01 p.m. confirmed that there was no physician's order for Resident 1 to use of an air mattress and that a bed safety evaluation that included the potential safety hazards created by the use of an air mattress was not completed for Resident 1. She also confirmed that there was no documented evidence of the settings for the resident's air mattress and no documented evidence that staff were checking the air mattress for proper inflation.

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



 Plan of Correction - To be completed: 03/24/2020

The following is being submitted for plan of correction purposes only and should not be construed as an admission.

1- Resident 1 no longer resides in facility.

2- Current residents who are on a specialty mattress were reviewed to verify they have orders that include the settings for the mattress that will be included in the electronic medical record. Current residents were reviewed for accuracy of bed safety evaluations.

3- Education on F 689 with licensed staff with a focus on identifying potential safety hazards caused by the equipment/mattress and settings for the mattress will be completed ensuring that the bed safety evaluation form should include the information. Education will be added to new hire and agency orientation.

4. Bed safety evaluations will be completed upon admission/readmission, quarterly, with falls and change in equipment. A random audit will be performed by wound care coordinator or designee on new admissions/readmission and any change in mattress equipment- daily x 2 weeks then weekly x 2 and monthly.
5. Results of monitoring will be reported to the Quality Assurance Performance Improvement Committee.

483.10(i)(4), 483.90(e)(2)(3) REQUIREMENT Resident Room Bed/Furniture/Closet: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(i)(4) Private closet space in each resident room, as specified in 483.90
(e)(2)(iv)

483.90(e)(2) -The facility must provide each resident with--
(i) A separate bed of proper size and height for the safety and convenience of the resident;
(ii) A clean, comfortable mattress;
(iii) Bedding, appropriate to the weather and climate; and
(iv) Functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident.

483.90(e)(3) CMS, or in the case of a nursing facility the survey agency, may permit variations in requirements specified in paragraphs (e)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations
(i) Are in accordance with the special needs of the residents; and
(ii) Will not adversely affect residents' health and safety.
Observations:


Based on review of clinical records and the facility's investigation documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents had a proper size bed for one of 17 residents reviewed (Resident 1).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 5, 2019, revealed that the resident required extensive assistance with bed mobility and was 69 inches tall and weighed 237 pounds. A nursing note, dated February 7, 2020, revealed that Resident 1 was re-admitted to the facility from the hospital, and a baseline care plan, dated February 7, 2020, indicated that the resident had a history of falls, required the assistance of one staff with bed mobility, and did not have an air mattress on his bed.

A bed safety evaluation for Resident 1, dated February 7, 2020, revealed that the resident had a standard size bed; the resident's size, weight or height were inappropriate for the size of the bed; and the resident's bed width was inappropriate for the resident to turn and reposition.

There was no documented evidence that the resident was provided with a bed that was appropriate for his size and needs.

Facility investigation documents, dated February 10, 2020, at 6:45 a.m. revealed that Nurse Aide 1 went to change Resident 1's sheets and when she rolled him away from her, his lower body slipped off of the bed.

Observations on February 11, 2020, at 4:42 p.m. revealed that Resident 1's bed was a standard size.

Interview with the Director of Nursing on February 11, 2020, at 6:09 p.m. confirmed that larger beds were available for residents and Resident 1 had a standard size bed.

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



 Plan of Correction - To be completed: 03/24/2020

The following is being submitted for plan of correction purposes only and should not be construed as an admission.

1- Resident 1 no longer resides in facility.

2- Current residents bed safety evaluations were reviewed for accuracy by restorative nurse.

3- Education of F917 with licensed staff with a focus on ensuring the resident(s) is/are provided equipment that is appropriate for their needs and documented on their bed safety evaluation form.

4- Bed safety evaluations will be completed upon admission/readmission, quarterly, with falls and change in equipment. A random audit will be performed by wound care coordinator or designee on new admissions/readmission and any change in mattress equipment- daily x 2 weeks then weekly x 2 and monthly.

5- Results of monitoring will be reported to the Quality Assurance Performance Improvement Committee.

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