Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-SHADYSIDE
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-SHADYSIDE
Inspection Results For:

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MANORCARE HEALTH SERVICES-SHADYSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on October 4, 2019, it was determined that Manorcare Health Services-Shadyside 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 related to the health portion of the survey process.





 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect for one of seven residents (Resident R1).

Findings include:

The facility policy "Patient Protection: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention" dated 1/31/19, indicated that each resident has the right to be free from neglect or the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Clinical record review revealed that Resident R1 was re-admitted to the facility on 8/12/19, with diagnoses that included right above the knee amputation, diabetes, peripheral artery disease, and high blood pressure. Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated 5/7/19, revealed he and his family wanted CPR with full treatment.

Clinical record review indicated that on 9/7/19, between 9:15 p. m. and 9:20 p. m. Resident R1's Licensed Practical Nurse (LPN) Employee E1 entered his room and found him unresponsive. LPN Employee E1 went out to the desk asking for help. LPN Employee E 1 checked Resident R1's chart to check for code status and CPR and full treatment was desired. LPN Employee E1 called the nursing supervisor while Registered Nurse (RN) Employee E2 rushed to the resident's room. The resident's pulses were not palpable, his face and neck were lukewarm to touch and his hands were very cold and discolored. The bed was flattened, head board placed underneath him with assist of two nurse aides and CPR was initiated at 9:25 p. m.. Oxygen mask was applied and put on maximum flow. At 9: 28 p. m., CPR was paused by RN Employee E3 and no pulses palpable and CPR was continued. At 9:32 p.m., CPR was paused by RN Employee E3 and no pulses palpable and CPR continued. At 9:37 p.m., CPR was paused by RN Employee E3 and no heart or lung sounds were noted. Resident R1's skin was very cool to touch and became more discolored. At 9:40 p.m., RN Employee E3 listened for heart and lung sounds and none present; pulses not palpable. At 9:45 p.m., RN Employee E3 called the code to end as Resident R1 had ceased to breathe.

During an interview on 10/1/19, at 11:10 a. m. the Nursing Home Administrator confirmed that Employees E1, E2, and E3 failed to provide timely emergency care, failed to summon EMS assistance, failed to utilize the AED as required and failed to summon guidance from the physician for Resident R1.

During an interview on 10/1/19, at 1:20 p. m. the Nursing Home Administrator confirmed that the facility failed to make certain that Resident R1 was free from neglect.

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

28 Pa. Code: 201.29 (a) (d) Resident rights.

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


 Plan of Correction - To be completed: 11/05/2019

Resident R1 CTB

All current residents and new admissions have the potential to be affected by deficient practice.

Emergency management procedure education to include initiation of EMS, use of AED, and CPR instruction of 100% of nursing staff by DON or designee.

Neglect and Abuse education of all facility staff will be conducted by DON or designee.

Using the Abaqis resident interviews adressing abuse/neglect, 5 resident interviews will be conducted weekly x 4 weeks with results reviewed during Eagle room process. Grievance process to be initiated for any concerns voiced. Any deficient practice to be investigated, reported, and performance improvement plan initiated.

Date of compliance: 11/05/2019

483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:

Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to provide timely emergency care and summon emergency medical personnel for one of seven residents (Resident R1).

Findings include:

The facility policy " Cardiopulmonary Resuscitation (CPR): Adult" dated 1/31/19, indicated that once victim is unresponsive, you shout for nearby help, activate emergency response system and get AED (Automatic External Defibrillator, a portable electronic device that automatically diagnoses life-threatening heart rhythm abnormalities) and emergency equipment or send someone to do so. If there is no breathing or only gasping and no pulse, begin CPR and use AED as soon as it arrives. When AED arrives, check rhythm and follow device instructions for shockable or non-shockable rhythm.

The facility policy "Emergency Management Emergency Response Guidelines" dated 1/31/19, indicated that the first person on the scene calls for assistance either by voice or emergency call light system. If not a nurse, notify the nurse immediately. Do not leave the patient alone unless immediate response is anticipated. The first licensed nurse to arrive on the scene, evaluates the patient and directs additional licensed nurse to review chart for code status. He/she then directs additional responder to page emergency code per established process and directs additional licensed nurse or staff member to phone emergency services requesting emergency assistance. Staff nearest the crash cart transports the crash cart and AED to the scene and sets up needed equipment per licensed nurse instruction. Licensed nurse instructs a staff member to wait by the facility emergency entrance in order to direct EMS (Emergency Medical Services) team to the scene. Facility staff continue management of the emergency until directed otherwise by the physician or upon arrival of EMS team personnel on site.

Clinical record review revealed that Resident R1 was re-admitted to the facility on 8/12/19, with diagnoses that included right above the knee amputation, diabetes, peripheral artery disease, and high blood pressure. Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated 5/7/19, revealed he and his family wanted CPR with full treatment.

Clinical record review indicated that on 9/7/19, between 9:15 p. m. and 9:20 p. m. Resident R1's Licensed Practical Nurse (LPN) Employee E1 entered his room and found him unresponsive. LPN Employee E 1 went out to the desk asking for help for resident being unresponsive. LPN Employee E 1 checked the resident's chart to check for code status, CPR and full treatment was desired. LPN Employee E1 called the nursing supervisor while Registered Nurse (RN) Employee E2 rushed to the resident's room. The resident's pulses were not palpable, his face and neck were lukewarm to touch and his hands were very cold and discolored. The bed was flattened, head board placed underneath him with assist of two nurse aides and CPR was initiated at 9:25 p. m.. Oxygen mask was applied and put on maximum flow. At 9: 28 p. m., CPR was paused by RN Employee E3 and no pulses palpable and CPR was continued. At 9:32 p.m., CPR was paused by RN Employee E3 and no pulses palpable and CPR continued. At 9:37 p.m., CPR was paused by RN Employee E3 and no heart or lung sounds were noted. Resident R1's skin was very cool to touch and became more discolored. At 9:40 p.m., RN Employee E3 listened for heart and lung sounds and none present; pulses not palpable. At 9:45 p.m., RN Employee E3 called the code to end as Resident R1 had ceased to breathe.

During an interview on 10/1/19, the Nursing Home Administrator confirmed that the facility failed to provide timely emergency care and summon emergency medical personnel for Resident R1.

28 Pa. Code: 201.4 (a) Responsibility of licensee.

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

28 Pa. Code: 201.20 (a) (b) Staff development.

28 Pa. Code: 201.29 (a) (d) Resident rights.

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

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






 Plan of Correction - To be completed: 11/05/2019

Resident R1 Ceased to Breathe.

All current residents and new admissions who are Full Code have the potential to be affected by deficient practice.

Emergency management procedure education to include initiation of EMS, use of AED, and CPR instruction of nursing staff will be completed by DON or designee.

Utilizing the Emergency management QAPI audit tool, all current residents POLST and code status orders were reviewed for accuracy by DON or designee.

New admission POLST and code status orders will be reviewed for accuracy through the Eagle room process by the unit manager/DON or designee.

Audit of licensed nursing staff for CPR certification will be completed by Human Resource Director or designee.

All current licensed nursing staff to obtain CPR certification by 11/5/2019.

Daily mock codes x1 week, then weekly on each shift x2 weeks, then monthly on each shift to be conducted by DON or designee.


Date of Compliance: 11/5/2019.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
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 facility policy, clinical and facility record review and staff interview, it was determined that the facility failed to make certain that licensed nurses had the specific competencies and skills necessary to care for residents' emergency care needs for one of seven residents (Resident R1).

Findings include:

The facility policy "Emergency Management" dated 1/31/19, indicated the first person on the scene calls for assistance either by voice or emergency call light system. If not a nurse, notify the nurse immediately. Do not leave the patient alone unless immediate response is anticipated. The first licensed nurse to arrive on the scene, evaluates the patient and directs additional licensed nurse to review chart for code status. He/she then directs additional responder to page emergency code per established process and directs additional licensed nurse or staff member to phone emergency services requesting emergency assistance. Staff nearest the crash cart transports the crash cart and AED (Automatic External Defibrillator, a portable electronic device that automatically diagnoses life-threatening heart rhythm abnormalities) to the scene and sets up needed equipment per licensed nurse instruction. Licensed nurse instructs a staff member to wait by the facility emergency entrance in order to direct EMS (Emergency Medical Services) team to the scene. Facility staff are to continue management of the emergency until directed otherwise by the physician or upon arrival of EMS (Emergency Medical Services) team personnel on site.

Clinical record review revealed that Resident R1 was re-admitted to the facility on 8/12/19, with diagnoses that included right above the knee amputation, diabetes, peripheral artery disease, and high blood pressure. Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated 5/7/19, revealed he and his family wanted CPR with full treatment.

Clinical record review indicated that on 9/7/19, between 9:15 p. m. and 9:20 p. m. Resident R1's Licensed Practical Nurse (LPN) Employee E1 entered his room and found him unresponsive. LPN Employee E 1 went out to the desk asking for help for resident being unresponsive. LPN Employee E 1 checked the resident's chart to check for code status, CPR and full treatment was desired. LPN Employee E1 called the nursing supervisor while Registered Nurse (RN) Employee E2 rushed to the resident's room. The resident's pulses were not palpable, his face and neck were lukewarm to touch and his hands were very cold and discolored. The bed was flattened, head board placed underneath him with assist of two nurse aides and CPR was initiated at 9:25 p. m.. Oxygen mask was applied and put on maximum flow. At 9: 28 p. m., CPR was paused by RN Employee E3 and no pulses palpable and CPR was continued. At 9:32 p.m., CPR was paused by RN Employee E3 and no pulses palpable and CPR continued. At 9:37 p.m., CPR was paused by RN Employee E3 and no heart or lung sounds were noted. Resident R1's skin was very cool to touch and became more discolored. At 9:40 p.m., RN Employee E3 listened for heart and lung sounds and none present; pulses not palpable. At 9:45 p.m., RN Employee E3 called the code to end as Resident R1 had ceased to breathe.

Facility record review revealed that LPN Employee E1 did not have evidence of CPR training and RN Employee E3 did not have evidence of facility cardiovascular skills and techniques training that includes CPR and AED emergency care.

During an interview on 10/1/19, at 1:20 p. m. the Nursing Home Administrator confirmed that the facility failed to make certain that licensed nurses had the specific competencies and skills necessary to care for residents' emergency care needs by failing to activate the EMS team, implement the use of the AED, and inform Resident R1's physician for emergency care instructions before stopping emergency care.

28 Pa. Code: 201.14 (a) Responsibility of licensee.

28 Pa. Code: 201.18 (a) (1) (3) (e) (1) Management.

28 Pa. Code: 201.20 (a) (b) (d) Staff development.

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



 Plan of Correction - To be completed: 11/05/2019

Resident R1 Ceased to Breathe.

Employee E1 remains in suspended state due to being out of country and will be terminated upon return from leave. Employees E2 and E3 have been terminated.

Emergency management procedure education to include initiation of EMS, use of AED, and CPR instruction of 100% of nursing staff. Emergency management education by DON or designee.

Audit of Licensed Nursing staff for completed skills technique validation.

All current licensed nursing staff to complete skills technique validation annually and all new hire licensed nursing staff to have skills technique validation in order to complete new hire orientation.

All current licensed nursing staff to obtain CPR certification and all new hire licensed nursing staff to provide proof of current CPR certification in order to complete new hire orientation.

Audit of 3 employee files for skills validation and CPR certification to be conducted by Human Resource Director or designee weekly x4 weeks.

Date of Compliance: 11/05/2019


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