Nursing Investigation Results -

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

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MANORCARE HEALTH SERVICES-WEST ALLEN
Inspection Results For:

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MANORCARE HEALTH SERVICES-WEST ALLEN - 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 February 4, 2020, it was determined that Manorcare Health Services - West Allen 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:


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that personal care including bathing was provided to one of seven sampled residents. (Resident CL1)

Findings include:

Clinical record review revealed that Resident CL1 was admitted to the facility on December 24, 2019, with diagnoses that included schizophrenia and ataxic gait. The Minimum Data Set assessment dated December 31, 2019, indicated that the resident was cognitively impaired and dependent on staff for personal hygiene and bathing. The resident was scheduled for showers on the day shift on Monday and Thursday. Review of the shower documentation for December 2019 and January 2020 revealed that the resident received a shower on four days from December 24, 2019 through January 22, 2020. There was no documentation to support that staff offered Resident CL1 a shower on the other four scheduled shower days.

In an interview on February 4, 2020, at 1:20 p.m. the Director of Nursing confirmed that there was no evidence to support that staff offered Resident CL1 showers as scheduled.

28 Pa. Code 211.12(d)(5)Nursing services.
Previously cited 5/22/19





 Plan of Correction - To be completed: 03/17/2020

CITED RESIDENTS: Resident #CL1. Resident no longer resides in the facility.

LIKE RESIDENTS: All residents have the potential to be affected by this deficient practice.
Utilizing the Rate Response Report, will verify that shower was provided according to schedule. Residents who refuse showers will be care planned accordingly.

CHANGE IN SYSTEM: to ensure the deficient practice does not re- occur, DON and/or designee will educate all licensed staff on the bathing policy to ensure all showers are completed/offered according to schedule.

MONITORING: Using the POC Rate Response Report will monitor completions of showers. DON or designee will audit 5 residents per floor per week to ensure showers were provided/offered according to schedule. All audit findings will be presented to QAPI committee for review and recommendation.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to monitor, assess, and treat an impaired skin area for one of seven sampled residents. (Resident CL1)

Findings include:

Clinical record review revealed that Resident CL1 was admitted to the facility on December 24, 2019, with diagnoses that included obesity. The Minimum Data Set assessment completed on December 31, 2019, identified that CL1 had moderate cognitive impairment. The nursing admission assessment completed on December 24, 2019, revealed that CL1 had redness around her groin. On December 25, 2019, the facility developed a care plan to address the redness around CL1's groin. Interventions included "treatments per physician order" however, there was no evidence that the physician was notified of CL1's impaired skin or that treatments were ordered. A physician note dated December 26, 2019, revealed that examination of the genitourinary area was deferred and the sacral area was not examined. There was no further evidence that the facility monitored CL1's impaired skin after December 25, 2019.

In an interview on February 4, 2020, at 12:45 p.m. LPN1 stated that staff was to notify the physician of impaired skin areas and monitor the area. In an interview on February 4, 2020, at 1:30 p.m. the Director of Nursing confirmed there was no further evidence that the facility monitored CL1's impaired skin after December 25, 2019.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 5/22/19



 Plan of Correction - To be completed: 03/17/2020

CITED RESIDENTS: Resident #CL1. Resident no longer resides in the facility.

LIKE RESIDENTS: New Admissions and Current residents who have a skin alteration have the potential to be affected by this deficient practice.
Using the skin QAPI tool, residents who we identify as having a skin alteration will be reviewed to ensure that treatments are in place or practitioners were notified and orders were obtained as needed.
Comprehensive Review of all current residents' skin utilizing the QAPI tool will be utilized to ensure all skin alterations have a treatment in place or practitioners were notified and orders obtained as needed

CHANGE IN SYSTEM: to ensure the deficient practice does not re- occur, DON and/or designee will educate licensed staff on the use of skin practice guide to ensure all skin alterations have treatments in place. Shower sheets and nursing notes will be reviewed during Eagle rooms.

MONITORING: Utilizing the Skin QAPI tool, The DON or designee will audit 5 residents per week who are identified with a skin alteration to ensure treatments were implemented timely. All findings of audits will be presented to QAPI committee for review and recommendation.


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