Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT NEW CASTLE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GROVE AT NEW CASTLE, THE
Inspection Results For:
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GROVE AT NEW CASTLE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, and State Licensure Survey completed on February 21, 2020, it was determined that The Grove at New Castle, was not in compliance with the 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:

483.24 REQUIREMENT Quality of Life:

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 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the
necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Observations:

Based on review of facility documentation and resident interviews, it was determined that the facility failed to meet the needs of residents in a timely manner regarding call bell response time for six of 13 residents (Residents R3, R28, R29, R30, R44, R51).

Findings include:

Resident Council minutes for time period of 11/26/19 through 1/20/20, revealed concerns with slow call bell response time during the evening and midnight hours.

During interviews on 2/18/20, from 12:45 p.m. through 2:15 p.m. Residents R3, R28 and R30 disclosed that on the night shift, the staff often refused to respond to the needs of the residents and frequently ignored call bells throughout the night.

During an interview on 2/18/20, at 1:30 p.m. Resident R51 verbalized "call bell response time is slow from 7:00 pm and into the night." Resident R51 indicated there have been times where he/she has waited up to an hour for staff assistance.

During an interview on 2/18/20, at 1:40 p.m. Resident R44 verbalized "I could be waiting for an hour to have someone help me after I put my light on during the midnight shift."

During an interview on 2/19/20, at 10:30 a.m. Resident R29 indicated that staff was slow to respond to call bells during the late evening hours and midnight hours. Resident verbalized, "if the staff did answer my call bell, they would be on their phone when they come into my room."

During a Resident Council meeting on 2/19/20, at 1:30 p.m., five of 13 residents in attendance, complained of poor call bell response times during the midnight shift hours (11:00 pm to 7:00 am.)

28 PA Code 201.29(j) Resident rights

Plan of Correction - To be completed: 03/10/2020

F675
1. The facility cannot correct that Resident R3,R28,R29,R30, R44 and R51 call bells were not answered timely.
2. The facility will ensure call bell are answered timely in order to meet the needs of the residents.
3. The nursing staff will be re-educated on the facility policy for answering call bells and cell phone usage by the Director of Nursing/designee.
4. The Director of Nursing/designee will audit call bell response times two times a week for 2 weeks, weekly for 2 weeks and monthly for three months. These audits will occur on all three shifts. The Guardian Angels will randomly ask residents during daily rounds if their needs are being meet timely on afternoon and night shifts. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:

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(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, the resident's responsible party received written notice, including the reason for the change, before the resident's room was changed for one of one residents reviewed with a room change (Resident R33).

Findings include:

Resident R33's clinical record revealed an admission date of 2/28/14, with diagnoses that included dementia and weakness.

A tour of the facility on 2/18/20, identified that Resident R33 no longer resided in Room 23, and was observed to have been moved to Room 12.

There was no documentation to indicate that Resident R33's responsible party received any written notice regarding the room change.

During an interview on 2/21/20, at 1:20 p.m. the Director of Nursing confirmed that Resident R33 was moved to a different room, but that written notification regarding the room change was not provided prior to the room change.

28 PA Code 201.14(a) Responsibility of licensee

28 PA Code 201.29(j) Resident rights

Plan of Correction - To be completed: 03/10/2020

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

F559
1. Resident R33's responsible party was notified by telephone on 2/20/20. Facility was unable to correct the fact that the responsible party was not notified timely in writing of the room change.
2. The facility will ensure residents/responsible parties receive written notice timely including the
reason for the room change before the change occurs.
3. The Social Service Director/designee will be re-educated by the Nursing Home Administrator/designee on providing written notice to residents/responsible parties when a room change is needed. Written notice will include the reason for the room change.
4. The Nursing Home Administrator/designee will audit resident room changes weekly for four weeks and monthly for three months to ensure residents/responsible parties have received written notice including the reason for the room change. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to discontinue the use of a catheter as the physician ordered for one of 19 residents (Resident R356).

Findings include:

Resident R356's clinical record revealed an admission date of 2/15/20, with diagnoses that included Alzheimer's disease, seizures, high blood pressure and heart problems.

The "Nursing Admission Screening/History" record revealed that Resident R356 was admitted with a catheter and to have bladder training and to discontinue the catheter on 2/17/20, written by Registered Nurse Employee E2.

The physician order, dated 2/15/20, revealed an order for "bladder training, Foley cath (catheter inserted into the bladder to facilitate urine drainage) clamp times 3 hours then unclamp times one hour until 2/17/20, then discontinue Foley cath/bag."

Observation on 2/19/20, at 1:40 p. m. revealed Resident R356 seated near the nurses station with a Foley catheter, draining urine into a catheter bag.

During an interview on 2/19/20, at 1:47 p.m. Registered Nurse Employee E3 confirmed that Resident R356 was still using the catheter and it had not been discontinued as the physician ordered.

28 PA Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/10/2020

F690
1. Resident R356's physician was notified 2/18/20 and orders to bladder train and remove catheter on 2/21/20 given.
2. The Director of Nursing will review current residents with catheters to ensure physician orders are being followed.
3. The licensed nursing staff will be re-educated by the Director of Nursing/designee on following physician orders with emphasis on catheter orders.
4. The Director of Nursing/designee will audit physician orders daily for two weeks, weekly for 2 weeks and monthly for three months to ensure physician orders are being followed. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) user's manual, facility documentation and clinical records and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of 19 residents (Resident R11).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument user's manual, dated October 2019, indicated that residents are to be assessed under Section N0410, for medications received (Number of times medication received in the lookback period of seven days).

Resident R11's clinical record revealed an admission date of 11/09/19, with diagnoses that included atrial fibrillation (irregular rapid heart rate). An Admission MDS, dated 11/15/19, revealed in "Section N0410 Medications received: (E), that the question "Medications received: Days: Anticoagulant" was marked as zero.

Review of the physician admission orders for Resident R11 revealed the resident was on an anticoagulant (Apixaban 5 milligrams twice a day) on admission.

During an interview on 2/20/20, at 10:46 a.m. Licensed Practical Nurse Assessment Coordinator Employee E1 confirmed that Section N0410 on the MDS dated 11/15/19, was not coded correctly regarding Resident R11's anticoagulant.

28 PA Code 211.5(f) Clinical records

28 PA Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/10/2020

I hereby acknowledge the CMS 2567-A, issued to GROVE AT NEW CASTLE, THE for the survey ending 02/21/2020, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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