Pennsylvania Department of Health
 SPIRITRUST LUTHERAN THE VILLAGE AT GETTYSBURG
Patient Care Inspection Results

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SPIRITRUST LUTHERAN THE VILLAGE AT GETTYSBURG
Inspection Results For:

There are  74 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SPIRITRUST LUTHERAN THE VILLAGE AT GETTYSBURG - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on May 2, 2024, it was determined that Spiritrust Lutheran The Village At Gettysburg 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:


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of sixteen residents reviewed (residents 17, 19, and 29).

Findings include:

Review of facility policy titled, "Comprehensive Care Planning Standard," last revised November 15, 2017, revealed, in part, "The care plan framework will include the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being...Care plans are evaluated and revised as the resident's status changes and with any goals or treatment refusals."

Review of Resident 17's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and fracture of the left humerus (bone in the part of the arm closest to the body).

Observation on Resident 17 on April 29, 2024, at 12:24 PM, revealed Resident 17 sitting in a wheelchair with no brace on her left arm. When questioned about the brace that was sitting on a chair behind where the resident was sitting, Resident 17 replied that she only wears the brace at nighttime. Resident 17 was also using supplemental oxygen at this time.

Review of Resident 17's care plan, on April 29, 2024, revealed an active care plan for, Activities of daily living function impaired due to left humeral fracture. This care plan had an intervention of hinged elbow brace to be work at all times, with a date initiated of February 16, 2024. Further review of Resident 17's care plan failed to reveal anything regarding Resident 17's supplemental oxygen use.

Review of Resident 17's physician orders on April 29, 2024, revealed a current physician's orders for supplemental oxygen at 2 liters per minute to start on March 24, 2024, and an order for Resident 17 to wear her hinged elbow brace at hours of sleep only starting on March 30, 2024.

Interview with the Director of Nursing (DON) on May 2, 2024, at 10:12 AM revealed that Resident 17's care plan should have been updated to include her use of supplemental oxygen and should have been updated when the physicians order for her hinged elbow brace changed to only be worn at hours of sleep.

Review of Resident 19's clinical record revealed diagnoses that included: muscle weakness, peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning).

Observation of Resident 19 in her room on April 29, 2024, at 10:13 AM, revealed she had a soft boot on her left foot, her other foot was covered by a blanket.

Review of Resident 19's care plan on April 29, 2024, at 12:45 PM, failed to reveal and notation of heel boots or heel protective devices.

During an interview with the DON on May 1, 2024, at 9:59 AM, she revealed Resident 19 wears heel protector boots to prevent skin breakdown (development of wounds).

Review of Resident 19's care plan on May 1, 2024, at 2:05 PM, revealed a focus area: "Potential for skin breakdown due to fragile skin, incontinence (the loss of bladder control), limited ability to move by myself, poor nutrition" initiated on April 12, 2024, with an intervention for "Apply heel protectors as needed for skin protection," initiated April 30, 2024.

Interview with the DON on May 2, 2024, at 10:04 AM, revealed she would expect the heel protectors to be on Resident 17's care plan prior to April 30, 2024.

Review of Resident 29's clinical record on April 30, 2024 at approximately 2:00 PM, revealed diagnoses that included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) and muscle weakness (lack of strength).

Review of Resident 29's physician orders revealed an order written on January 12, 2024 to apply left resting hand splint upon rising in the morning and remove at bedtime.

Review of Resident 29's comprehensive care plan failed to reveal a focus area or intervention for the use of a left-hand splint.

During an interview on May 1, 2024 at 1:15 PM, with the Nursing Home Executive Director and Director of Nursing (DON) the surveyor requested additional information regarding Resident 29's care plan not including the left hand splint.

During a follow up interview on May 2, 2024 at 10:12 AM with the Nursing Home Executive Director and DON, the DON stated the Resident 29's care plan had been revised to include use of the left-hand splint. The DON also stated it was the facility's expectation that the care plan would have been updated timely.

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


 Plan of Correction - To be completed: 06/18/2024

1. Resident #17, 19, 29 care plan has been revised to reflect current orders
2. Current Residents care plans will be reviewed to assure the care plan reflects current orders
3. Licensed nurses will be reeducated on the policy "Comprehensive Care Planning Standard" to assure the care plan framework will include the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and Psychosocial well-being. Care plans are evaluated and revised as the resident's status changes and with any goal or treatment refusals.
4. Audits will be completed by Director of Nursing or designee of 3 resident care plans weekly for 4 weeks and then monthly for 3 months " to assure the care plan framework will include the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and Psychosocial well-being. Care plans are evaluated and revised as the resident's status changes and with any goal or treatment refusals. Finding will be presented to Quality Assurance and Performance Improvement committee for review and recommendations.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on policy review, observation, record review, and staff interviews, it was determined the facility failed to provide appropriate care and services for residents receiving a tube feeding for one of 16 residents reviewed (Resident 19).

Findings include:

Review of facility policy, titled "Tube Feeding Standard", last revised April 1, 2016, revealed, in part, "Feeding solution is hung per manufacturer recommendations. All bags and tubing are replaced daily. Irrigation syringes are labeled with resident name, date, and are changed daily on 11-7 shift."

Review of Resident 19's clinical record revealed diagnoses that included: surgical aftercare following surgery on the digestive system, dysphagia (difficulty swallowing), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 19's physician orders revealed an order for "Enteral Feed every night shift, Change Enteral Feeding set, container bag, tubing", with a start date of April 13, 2024.

Observation in Resident 19's room on April 30, 2024, at 12:02 PM, revealed Resident 19's enteral feed tubing and the hanging bag of water for flushing were dated April 29, 2024, at 2:50 AM.

During an interview with the Director of Nursing (DON) on April 30, 2024, at 1:12 PM, the surveyor revealed the observation of the tubing and water bag not dated as changed on the prior night shift.

During a follow-up interview with the DON on May 1, 2024, at 9:57 AM, she revealed the tubing was not changed on night shift on April 30, 2024, and she would expect tubing and hanging bags to be changed per physician order and facility policy.

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


 Plan of Correction - To be completed: 06/18/2024

1. Resident 19s tubing and the hanging bag of water for flushing was changed per doctor's order
2. There is no other residents in the facility with Enteral feeding
3. Licensed nurses will be reeducated on the policy "Tube Feeding Standard" of Feeding solution is hung per manufacturer recommendations. All bags and tubing are replaced daily. Irrigation syringes are labeled with resident name, date and are changed daily on 11-7 shift".
4. Audits will be completed by Director of Nursing or designee of resident with Eternal Feeding weekly for 4 weeks and then monthly for 3 months to assure of Feeding solution is hung per manufacturer recommendations. All bags and tubing are replaced daily. Irrigation syringes are labeled with resident name, date and are changed daily on 11-7 shift. Tube feeding bags and tubing will be changed daily on 3-11 shift. Finding will be presented to Quality Assurance and Performance Improvement committee for review and recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for one of five residents reviewed for unnecessary medications (Resident 24).

Findings include:

Review of facility policy titled "Drug Regimen Review" last revised February 2023, read, in part "A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physicians and the care planning team. This should be: Documentation of the date each medication regimen review is completed on the appropriate form and notation of the finding in the medical record or other designated site."

Review of Resident 24's clinical record revealed diagnoses that included: Myasthenia gravis (a neuromuscular disorder that leads to weakness of skeletal muscles), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 24's clinical record on April 30, 2024, at 9:30 AM, failed to reveal a medication regimen review completed by a licensed pharmacist in the month of November 2023.

Email correspondence with the Director of Nursing (DON) on May 1, 2023, at 9:40 AM, revealed "I cannot locate the pharmacy recommendation for November 2023 for [Resident 24]."

During a follow up interview with the DON on May 1, 2023, at 1:45 PM, she confirmed she was unable to locate Resident 24's pharmacy recommendation from November 2023, and she would expect pharmacy recommendations to be available and reviewed by the physician.

28 Pa. Code 211.9(k) Pharmacy services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 06/18/2024

1. Resident 24s Drug Regimen Review was reviewed with the MD. No changes made to drug Regimen.
2. Residents charts will be reviewed ensure a current monthly pharmacy review was completed
3. Licensed nursed will be reeducated on the policy "Drug Regimen Review". A record of the consulting pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physicians and the care planning team. This should be: Documentation of the date each medication regimen review is completed on the appropriate form and notification of the finding in the medical record or other designated site.
4. Audits will be completed by Director of Nursing or designee of 3 resident medication regimen review/recommendation by the licensed pharmacist weekly for 4 weeks and then monthly for 3 months to assure " A record of the consulting pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physicians and the care planning team. This should be: Documentation of the date each medication regimen review is completed on the appropriate form and notification of the finding in the medical record or other designated site. . Finding will be presented to Quality Assurance and Performance Improvement committee for review and recommendations.


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