Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT GETTYSBURG, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT GETTYSBURG, THE
Inspection Results For:

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

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GARDENS AT GETTYSBURG, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an Abbreviated survey in response to a complaint and incident investigation completed on September 25, 2019, it was determined that The Gardens 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 clinical record review, review of select facility documentation, as well as staff interview, it was determined that the facility failed to implement established interventions for transfers to prevent an accident during showering, resulting in harm from a fall with a fracture to the resident's right ankle requiring the resident to be hospitalized and have surgical repair to the right ankle for one of three residents reviewed (Resident 1).

Findings include:

Review of Resident 1's clinical record revealed diagnoses that included multiple sclerosis (a slow progressive disease of the central nervous system)

Review of Resident 1's care plan for fall risk, effective February 15, 2017, revealed an intervention to transfer with the assistance of two staff. Review of Resident 1's Focus sheet (a summary of a resident's needs which Nurse Aides (NA) are to refer to provide care), updated August 3, 2019, states that Resdient 1 is a two assist with transfers.

Review of Physical Therapy discharge summary dated March 29, 2019, revealed Resident 1 was a moderate assist of 2 with transfers.

Review of facility's incident report dated August 5, 2019, revealed that Resident 1 experienced a fall on this date. Further review of the incident report revealed Nursing Assistant (NA) 1 had gotten Resident 1 out of the shower when she stated she needed to sit down, the NA was positioning the wheelchair when resident "lowered herself to the floor" and her right ankle twisted underneath her. A lift was used to assist the Resident 1 from the floor and into bed, a Registered Nurse (RN) assessment was done with Resident 1 crying out in pain when her right ankle was assessed. Swelling and pain were evident, ice was applied and Tylenol given. Resident 1 was sent to the hospital where X-rays revealed a fracture to Resident 1's right ankle. Surgery was scheduled for August 12, 2019. The facility's investigation of the fall revealed that NA 1 was educated regarding Resident 1 being listed on the focus sheet and the care plan as a two person assist and should have had another staff member assist with providing care to the resident in the shower room.

During an interview with the Director of Nursing (DON) on September 25, 2019, at 2:15 PM, she revealed that NA 1 should have followed the Resident 1's care plan.

The facility failed to implement established transfer interventions to assure Resident 1's safety during showering, which resulted in harm from a fall with a fractured ankle requiring hospitalization and surgery for one of three residents reviewed (Resident 1).

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

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

28 Pa. Code 201.18(b)(3) Management.

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

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

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

28 Pa. Code 211.11(d) Resident care plan.
.
28 Pa. Code 211.12(c) Nursing services.

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

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

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





























 Plan of Correction - To be completed: 10/24/2019

F 689 Accidents/Hazards/Supervision/Devices
1. How the facility will correct the deficiency as it relates to the individual.
NA #1 has been reeducated on following the resident's plan of care for appropriate staff assistance when providing a shower.
2. How facility will act to protect residents in similar situations?
Residents requiring assistance with showers have the potential to be affected by this alleged deficient practice. These residents will have the appropriate staff assistance/transfer interventions provided. An audit has been conducted of care plans for residents receiving showers to ensure the appropriate staff assistance is identified
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Nursing staff will be educated on following the resident's plan of care to ensure the appropriate assistance and transfer interventions are being provided. Nursing staff will also be provided Directed in-servicing on federal regulation F 689 and the accompanying guidelines for these regulatory requirements.
4. How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?
DNS or designee will conduct random observations of residents receiving showers to ensure the appropriate staff assistance and transfer interventions are being provided. These audits will be completed weekly times four and monthly times two or until substantial compliance has been achieved. Results will be reported to the Quality Assurance Committee for further recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(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 observation, clinical record review and staff interview, it was determined the facility failed to review and revise the resident's care plan for two of four residents reviewed (Residents 3 and 4).

Findings Include:

Review of Resident 3's September 2019, physician orders revealed diagnoses including Clostridium difficile (C-diff-an internal bacteria that causes chronic diarrhea) for which he is prescribed medication and is ordered to be on contact precautions.

Review of Resident 3's interdisciplinary plan of care revealed no focus area to address the c-diff or the contact precautions.

Review of Resident 4's clinical record revealed diagnoses including head lice and a physician order to repeat lice treatment in one week. Review of Resident 4's focus sheet ( a summary of a resident's needs which Nurse Aides (NA) are to refer to provide care) revealed she is to be on contact precautions until September 26, 2019.

Review of Resident 4's interdisciplinary plan of care revealed no focus area to address the head lice or the contact precautions.

Interview with the Director of Nursing, on September 25, 2019, at approximately 2:15 PM. revealed that the care plan should have been updated to reflect the aforementioned c-diff and head lice.

28 Pa. Code 211.11(d) Resident care plan




 Plan of Correction - To be completed: 10/24/2019

F 657 D Care plan Timing and Revision
1. How the facility will correct the deficiency as it relates to the individual.
Resident #3 care plan was reviewed and revised to include MSRA .
Resident #4 care plan was reviewed and revised to include lice

2. How facility will act to protect residents in similar situations?
Resident on Contract precautions for C-diff and head lice have the potential to be affected by this alleged deficit practice. These residents will have their care plans reviewed and revised to reflect the appropriate precautions.
Care plans of residents with C-diff and head lice have been audited to ensure the focus area is listed to address precautions.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Nursing staff will be educated on ensuring care plans are reviewed and revised timely to reflect focus areas that specifically address appropriate precautions as applicable.
4. How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?
DNS or designee will conduct random audits of care plans for residents with Cdiff and/or head lice to ensure these focus areas are listed and the appropriate precautions identified. These audits will be completed weekly times four and monthly times two or until substantial compliance has been achieved. Results will be reported to the Quality Assurance Committee for further recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observation, policy review and staff interview, it was determined that the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for one of four residents observed (Resident 4).

Findings include:

Review of facility policy, "Isolation - Initiating Transmission-Based Precautions," revealed, "Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment." The policy goes on to state that while caring for a resident staff will wear gloves(clean, non-sterile) when entering a room and will wear a disposable gown upon entering the room.

During an interview with a Nurse Aide on September 25, 2019 at 9:30 AM it was revealed she would use disposable gown to provide care.

Surveyor observation on September 25, 2019, at 12:00 PM, revealed a personal protective equipment storage container (portable kit containing items needed for personal protection such as gowns, gloves and hair nets) in the hallway outside of Resident 4's room. Observation at that same time revealed that an Activity Aide (AA) 1 was in the room preparing to paint Resident 4's fingernails. The AA 1 was wearing a hair covering and no other protective equipment.

During an interview with the Director of Nursing at the time of the observation, she confirmed Resident 4 was on contact precautions for head lice. She also revealed that staff providing care, including nail painting, should wear the protective equipment.

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
















 Plan of Correction - To be completed: 10/24/2019

F 880 Infection Prevention and Control
1. How the facility will correct the deficiency as it relates to the individual.
Activities Aide#1 was educated on infection control policy and procedures for transmission based precautions.
2. How facility will act to protect residents in similar situations?
Residents on contact precautions that are receiving one to one activities have the potential to be affected by this alleged deficient practice. These residents will have the appropriate PPE utilized by staff.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Activities aides have been reeducated on infection control policy and procedures for providing activities to residents on transmission based precautions and ensuring appropriate PPE is utilized.
4. How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?
Administrator or designee will conduct random observations of residents on contact precautions that are receiving one to one activities to ensure that the appropriate PPE is being utilized by staff. These audits will be completed weekly times four and monthly times two or until substantial compliance has been achieved. Results will be reported to the Quality Assurance Committee for further recommendations.



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