Nursing Investigation Results -

Pennsylvania Department of Health
LACKAWANNA HEALTH AND REHAB CENTER
Patient Care Inspection Results

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LACKAWANNA HEALTH AND REHAB CENTER
Inspection Results For:

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LACKAWANNA HEALTH AND REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 18, 2020, it was determined that Lackawanna Health and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


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 follow physician orders for the administration of a prescribed bowel regimen for one resident out of nine sampled (Resident CR1).

Findings include:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on December 20, 2019, with diagnoses that included hypertension, osteoarthritis and vascular dementia (form of dementia caused by an impaired supply of blood to the brain).

The resident had physician orders dated January 2020, for a bowel protocol, which indicated that if the resident did not have a bowel movement documented for 3 days, the resident was to receive Milk of Magnesia 30 mL at 5:00 p.m., If there was no bowel movement by day 4, the resident was to receive a Dulcolax suppository at 8:00 p.m., and if no bowel movement by day 5, the resident was to receive a Fleets enema at 8:00 pm.

According to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week.

A review of Resident CR1's January 20202 bowel records and MAR (medication administration records) revealed that the resident did not have a bowel movement on January 14, 15, 16 or 17, 2020, and staff did not administer Milk of Magnesia as ordered for no bowel movement after 3 days.

Interview with the director of nursing on February 18, 2020, at approximately 2:00 p.m. confirmed that staff failed to follow physician orders to promote bowel activity.


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



 Plan of Correction - To be completed: 03/25/2020







Resident CR1 was discharged from the facility.

A review of all current residents for the past 7 days was conducted to determine if bowel protocols/orders were accurately carried out.

All Nursing staff were in serviced on bowel Protocols and documentation of same.

Daily audits x 2 weeks, weekly x 4 weeks, and monthly x 3 months will be conducted to ensure appropriate and correct follow through with prescribed bowel protocols.

Results of these audits will be discussed and reviewed at the monthly QAPI Committee x 3 months.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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) Assisted nutrition and hydration.
(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)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to timely assess the adequacy of food and fluids intake and implement measures necessary to maintain adequate nutritional parameters and hydration status of one resident out of nine residents sampled (Resident CR1).


Findings include:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on December 20, 2019, with diagnoses that included hypertension, osteoarthritis and vascular dementia (form of dementia caused by an impaired supply of blood to the brain).

A review of Resident CR1's admission physician orders revealed an order for Ensure Plus (a nutritional supplement) three times a day with meals. Staff were to record the amount consumed; 100% consumed would be documented as a 4, 75% consumed would be documented as a 3, 50% consumed would be documented as a 2 and 25% consumed would be documented as a 1 according to the facility's documentation tool.

A review of documentation in the clinical record dated December 21, 2019, at 11:30 a.m. revealed that the resident's appetite was noted as fair.

A review a Nutritional Assessment completed December 22, 2019, revealed that the dietitian's recommendations were for staff to encourage fluids every shift and weekly weights in place for 4 weeks for close observation. The dietitian noted "Intake (measurement of fluid intake by mouth) and output (measurement of fluid eliminated as urine) in place" and "fair appetite noted, at times refuses food and fluids when offered per staff, goal is to maintain weight with no significant change over the next review, will also add magic cup (4 oz frozen cup supplement that provides calories and protein) at hs \ for additional nutritional support."

A review of Resident CR1's weekly weights revealed that upon admission to the facility on December 20, 2019, the resident's weight was recorded as 106.8 lbs. The resident's weight increased on December 27, 2019 with a recorded weight of 107.4 lbs, but then began to decline. On January 6, 2020 the recorded weight was 107.1 lbs, on January 10, 2020, the recorded weight was 102.6 and on January 17, 2020 the recorded weight was 100.4 lbs. A total of 7 lbs or 6.5% weight loss of body weight in approximately 3 weeks.

A review of documentation of Resident CR1's meal consumption dated January 11, 2020, through January 23, 2020, revealed that the resident consumed only 25% of her meals for 31 meals and 0% for 6 meals out of 39 meals served to the resident during that time period.

A review of Resident CR1's medication administration record revealed that on January 17, 2020, through January 23, 2020, the resident consumed only 50% of the supplement, Ensure Plus on 14 ocassions and only 25 % of the nutritional supplement on five ocassions out of the 21 times the supplement was provided.

There was no documented evidence Resident CR1's fluid intake and output had been monitored as planned according to resident's Nutritional Assessment.

Interview with Dietitian on February 18, 2020, at 1:58 p.m. revealed that for the dietitian to be made aware of nutritional concerns, nursing must complete a communication form and submit it to dietary. The dietitian confirmed that there was no documented evidence that Resident CR1's fluid intake and output were monitored and evaluated for adequacy in meeting the resident's fluid needs for adequate hydration.

A review of documentation in the clinical record dated January 15, 2020, at 7:00 a.m. revealed that the resident had not urinated during the 11:00 p.m. to 7:00 a.m. shift.

Documentation in the clinical record dated January 24, 2020, at 7:00 p.m. revealed that the resident was "lethargic, not responding to verbal stimuli." The physician ordered that the resident be sent to the hospital for evaluation.

A review of documentation in the clinical record dated January 25, 2020, at 3:00 a.m. revealed that Resident CR1 was admitted to the hospital with sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues).

A review of Resident CR1's hospital record dated January 24, 2020, revealed that upon arrival to the emergency room the resident was hypernatremic (high concentration of sodium in the blood which most often occurs in people who don't drink enough water) with a blood sodium level greater than 180 mEq/L (milliequivalents per liter). (A normal blood sodium level is 135 mEq/L to 145 mEq/L).

Further review of the resident's hospital record revealed that the resident required immediate treatment with intravenous fluids to correct the high sodium level.

There was no indication that Resident CR1's decreased food and fluid consumption were timely and effectively monitored and evaluated for meeting the resident's nutrition and hydration needs.


28 Pa. Code 211.6 (d) Dietary services

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





 Plan of Correction - To be completed: 03/25/2020






Resident CR1 was discharged from the facility.

Current residents appetite/fluid intake were reviewed for the past 10 days to determine physician/dietician notifications.

Weight policy reviewed and updated. Nursing staff and dietitians inserviced on weight policy.

Nursing staff was in serviced on Nutrition/Hydration and notification of physician/dietitian timely.

Unit manager will audit MAR's for supplement consumption daily x 2 weeks, weekly x 4 weeks and monthly x 3 and notify dietitian/physician as warranted.

DON/designee will audit meal consumption/intake and output to ensure adequate consumption and determine if any notifications need to be made daily x 2 weeks, weekly x 4 weeks, monthly x 3 months.

Results of these audits will be forwarded monthly to the facility's QAPI Committee for review and recommendations.


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on a review of clinical records, select facility policy and facility investigative reports and staff interview, it was determined that the facility failed to notify the resident's representative of accidents and injury for one resident out of nine sampled (Resident CR1).

Findings included:


A review of the facility policy entitled "Calls to a Physician, Residents, or Responsible party(s), Routine and Emergent for Notice of Change in Condition" revealed that for emergencies, the resident or designated responsible party is to be notified of the emergent changes. Licensed staff will call the responsible party noted on the face sheet. When the responsible party is unable to be reached by phone their alternate may be notified for contacting purposes only. Routine calls to the physician which are considered to be notification of x-rays or diagnostic studies within normal limits, notification of room change, routine daily departmental recommendations and orders needing his/her attention. The resident or responsible party is to be made aware of the routine changes in condition after the physician has been made aware. Licensed staff will call the responsible party noted on the face sheet. If notified by phone this must be documented, their response must also be documented on the chart with their return call and that they have confirmed receiving the new change in condition information with the staff member accepting the call.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on December 20, 2019, with diagnoses that included hypertension, osteoarthritis and vascular dementia (form of dementia caused by an impaired supply of blood to the brain).

According to Resident CR1's face sheet, both her son and daughter were listed as the resident's representatives for notification purposes.

A review of the Resident CR1's clinical record revealed that on December 21, 2019, a nurse documented at 8:45 p.m. that the "resident fell in back room" and was "complaining of R \ hip pain, will not walk which walking is her baseline." The entry noted that "a message was left for the POA (power of attorney)." Further review of documentation revealed that the resident was sent to the emergency room for evaluation and nursing noted that "Life Geisinger (an area program for older adults designed to give them the support services they need to live at home) updated."

A review of information provided by the facility dated December 21, 2019, at 7:45 p.m. revealed that the resident's son was notified at 8:00 p.m. of the resident's fall that required transfer to the emergency room for an evaluation.
However, documentation in the clinical record dated December 22, 2019, at 6:30 a.m. revealed that upon return from the emergency room the facility "called son's # \ numerous times, kept saying # not in service, no other # noted."

There was no documented evidence that the facility attempted to contact the resident's daughter when the resident's son could not be reached for notification of the fall and hospital transfer.

A review of information provided by the facility dated December 29, 2019, at 6:15 p.m. revealed that the nurse was notified that Resident CR1 had a bruised area near her left eye, "origin unknown". According to the documentation, the resident's son was notified of the bruise at 7:10 p.m. However, a review of documentation in CR1's clinical record dated December 29, 2019, at 6:15 p.m. revealed that the nurse was notified of a bruised area to the resident's left eye area, "origin unknown." A call was placed to the RP (responsible party) the resident's son, "the call did not go through due to number not in service. Tried multiple times".

There was no documented evidence that the facility attempted to contact the resident's daughter when the resident's son could be reached for notification of the injury of unknown origin.

There was no documented evidence in the clinical record that either the facility had reached the resident's son or daughter to notify either of them of the resident's fall on December 21, 2019, and/or the bruise on the resident's left eye on December 29, 2019.

Interview with the Director of Nursing on February 18, 2020, at approximately 2:00 p.m., confirmed that Resident CR1's family member, identified as representative contacts, were timely notified of the resident's changes in condition.




28 Pa. Code 211.12 (a)(c) Nursing services.

28 Pa. Code 201.29(a) Resident rights





 Plan of Correction - To be completed: 03/25/2020





Resident CR1 was discharged from the facility.

Current resident incident reports will be reviewed for the past 30 days for documentation of proper and timely notifications.

Notification of change policy updated and licensed nursing staff was in serviced on Notification of Changes to both resident's next of kin/POA and physician.

DON /designee will audit all incident/accident reports daily x 4weeks, weekly x 4 weeks, monthly x 3 months to ensure proper and timely notifications.

Results will be discussed and reviewed at the Monthly QAPI meeting x 3 months

201.14(c) LICENSURE Responsibility of licensee.:State only Deficiency.
(c) The licensee through the administrator shall report to the appropriate Division of Nursing Care Facilities field office serious incidents involving residents. As set forth in Section 51.3 (relating to notification). For purpose of this subpart, references to patients in Section 51.3 include references to residents.
Observations:

Based on a review of clinical records and incident/accident reports and staff interview it was determined that the facility failed to report to the State Licensing Agency, Division of Nursing Care Facilities an accident resulting in transportation to the hospital emergency room for one resident (Resident CR1) out of four sampled.

Findings include:

A review of Resident CR1's clinical record revealed that on December 21, 2019, the resident sustained a fall and complained of right hip pain. Nursing documentation indicated that the resident would not walk, which she was not normal for her and the physician was called. The physician ordered the resident to be sent to the emergency room to be evaluated.

A review of information provided by the facility dated December 21, 2020, at 7:45 p.m. revealed that Resident CR1 had an unwitnessed fall. The resident complained of right hip pain after the fall and was transferred to the emergency room for an evaluation.

This resident's accident and transfer to the emergency room was not reported to the Division of Nursing Care Facilities, Scranton Field Office.

An interview with the Director of Nursing on February 18, 2020, at approximately 1:30 p.m. verified that the facility did not notify the Division of Nursing Care Facilities of this resident's fall with transfer to the emergency room (event type Transfer/ Admission to Hospital Because of Injury/ Accident).



 Plan of Correction - To be completed: 03/25/2020









P0410 Resident CR1 was discharged from the facility.

Current residents incident reports will be reviewed for the past 30 days for proper notification to the State Licensing Agency, Division of Nursing Care Facilities as required.

Licensed nursing staff were inserviced on reportable incidents/accidents.

DON/designee will audit incident reports daily at morning meeting to determine notification to the Division of Nursing Care Facilities. The results of the audits will be forwarded to the monthly QAPI meeting for discussion and review.


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