Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT SKILLED CARE CENTER AT LIMA ESTATES
Patient Care Inspection Results

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WILLOWBROOKE COURT SKILLED CARE CENTER AT LIMA ESTATES
Inspection Results For:

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WILLOWBROOKE COURT SKILLED CARE CENTER AT LIMA ESTATES - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on Medicare Recertification, State Licensure, and a Civil Rights Compliance survey completed on June 10, 2022, it was determined that Willowbrooke Court Skilled Care Center at Lima Estates 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 as they relate to Health portion of the survey process.


 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's orders for one of 13 residents reviewed (Resident 35).

Findings include:

Review of Resident 35's clinical record revealed a physician's order dated January 5, 2022, for FentaNYL (narcotic pain reliever) Patch 72 Hour 12 micrograms/hour - Apply 1 patch transdermally (to the skin) every 72 hours for pain and remove per schedule and an order dated August 4, 2021, to check the placement of the patch every shift.

Review of Resident 35's progress notes revealed a nurse's note dated February 21, 2022, which stated, "Upon checking the pain patch, was noted that most staff had stated that it was on the RUB [(right upper back)] but was on the LUB [(left upper back)] and had not been changed since 2/16. It was omitted on 2/19. Therefore, a new patch was applied to the RUB and the old patch from 2/16 was removed from the LUB."

Review of Resident 35's February 2022 Medication Administration Record (MAR) revealed the FentaNYL patch from February 16, 2022 was documented as being removed on February 19, 2022 with a new patch placed the same date. Further review of Resident 35's February 2022 MAR revealed staff documented checking the placement of the patch on every shift from February 19, 2022 to February 21, 2022.

Interview with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m. confirmed staff failed to follow physician's orders in changing Resident 35's FentaNYL patch and checking for placement of the patch each shift.

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





 Plan of Correction - To be completed: 07/15/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the fact alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of federal and state law. The plan of correction represents the facility's credible allegation of compliance.

A. The identified deficient practice was past occurrence. The Fetanyl patch order for resident C35 is current and is being administered as ordered. A medication error form was completed as per facility protocol. Both MD and the POA were made aware. Resident C35 continues to be monitored for any increase in pain or change in mental status.

B. All residents have the potential to be affected. All current residents prescribed a Fetanyl patch were reviewed. Staff nurses were in-serviced on proper documentation and placement of Fetanyl patches according to physician orders. Pharmacy review completed to ensure orders read appropriately. Medication pass review also conducted by the pharmacy nurse consultant on 3/24/2022.

C. Random audits will be completed weekly x4, then monthly x2 by the DON/designee to ensure proper placement and documentation of patches. All Fetanyl patches are to be disposed of by 2 nurses. The narcotic count sheet will be verified by the two nurses at the change of shifts, and the completed narcotic count sheet are given to the DON for a final check.

D. Results of the audits will be presented to the QAPI committee for review.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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, staff interview and review of facility policy, it was determined that the facility failed to ensure two of 13 residents reviewed received adequate supervision resulting in an elopement and a fall during a transfer using a lift (Residents 33 and 35).

Findings include:

Review of facility policy "Elopement/Wandering Risk Assessment" reviewed June 13, 2022, revealed that "When responding to an alarm, if it cannot be determined what triggered the alarm, immediately verify that every resident is safe and accounted for by conducting a visual head and name reconciliation"

Review of Resident 33 progress notes dated June 1, 2021, at 11:46 p.m. revealed "Approx. 7 p.m. this Nurse investigated a door alarm coming from Admin (administration) area; alarm computer was checked but did not indicate a code alert (alert notifying staff that a resident wandered outside of their designated area by a wearable tracker); this Nurse followed the sound to the door near Administration offices; no one was observed outside or inside. A surgical mask was found on the floor near the steps by the BR (bathroom) door in the same area."

Review of Resident 33's progress notes dated June 1, 2021, at 11:46 p.m. revealed "Approx. 7:20 p.m., this Nurse arrived @ (at) Res (resident) room to admin (administer) meds (medications) & (and) discovered Res was not in her room nor in her BR (bathroom). Call light was not on. Immediately, Activities Area was checked & all rooms/BR's on unit were checked for Res. When Res not found on unit, Security was notified."

Review of Facility's investigation documentation for Resident 33's elopement dated June 1, 2021, revealed that staff did not conduct a visual head and name reconciliation when a door alarm was triggered by unknown means.

Interview with the facility's Nursing Home Administrator and the Assistant Director of Nursing on June 10, 2022, failed to provide any documentation showing that staff conducted a visual head and name reconciliation as per facility policy "Elopement/Wandering Risk Assessment".

The facility failed to provide Resident 33 with adequate supervision, which resulted in Resident 33 eloping from the facility for 20 minutes before the facility recognized resident was missing.

Review of facility policy "Lifting/Transferring/Repositioning Resident Safely," last revised December 2018 revealed: "Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance."

Review of Resident 35's annual Minimum Data Set (MDS - periodic assessment of resident's needs) dated February 18, 2022 revealed the resident required an extensive assistance with two staff persons for transfers and had impairment to both upper and lower extremities.

Review of Resident 35's care plan revealed the resident was at risk for falls due to unsteady gait and poor balance, with an intervention added October 23, 2018 to "Please allow me to have assistance with 2 staff persons using Hoyer lift during transfers, toileting and [activities of daily living.]"

Review of Resident 35's progress notes revealed a nurse's note dated April 7, 2022, which stated, "On 4/6/22 at [7:30 p.m.]. The nurse was called into the residents room by staff. The resident was assisted to the floor by [nurse aide.] The resident was on the VERA LIFT. While on the lift the resident let go of the handles and began to fall. The [nurse aide] then assisted the resident to the floor. The resident was free from injury." The note further indicated the root cause of Resident 35's fall was: "The resident was being transfer using a lift with only one person. All lifts required 2 staff members."

The facility's failure to have two staff persons present while assisting Resident 35 during a transfer in the lift which resulted in a fall was discussed with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m.

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies





 Plan of Correction - To be completed: 07/15/2022

Part I.
A. To ensure residents safety, after elopement the resident was immediately given a code alert bracelet and shall receive ongoing elopement assessments. The nursing staff in-serviced on elopement policies and procedures.

B. Elopement binders were placed at welcome house, main office, and the nursing station to ensure all staff are aware of residents at risk for elopement. All nursing staff have a code alert pager that are worn at all times during shift that alert staff what resident is alarming. Staff were re-educated on how to respond properly using the pager system. Residents are assessed for elopement risk on admission, after 72 hours, 30 days, and quarterly. The WillowBrooke Skilled Court Center (WBC) staff were educated on what s/s to look for to identify someone that may elope, so proactive intervention can be in place to prevent elopement from occurring.

C. The Security Officers in Welcome House have pagers as well. Once the code alert alarms, the nursing staff respond and deactivate alert once the resident is visualized. Security then calls nursing to verify the resident is visualized. A report is written and completed for every code alert alarms to ensure procedure is followed.

D. Elopement status will be reviewed weekly during the standard of care meeting to ensure appropriateness of current residents and assess if any resident should be added to the list. A weekly elopement drill to be conducted x 4 weeks then monthly x2. The results will be presented to the QAPI committee for review.


Part II.
A. The deficient practice was past occurrence. The nurse was called into the room after the resident was lowered to the floor by the CNA. The resident was assessed with no injury noted. MD and the POA were made aware. No new orders. The CNA was given a performance counseling for following policy/procedure on proper lifting/transferring. Nursing staff were re-educated on proper techniques used to transfer residents with a mechanical lift.

B. The resident's transfer status is documented under special instruction tab in PCC that can be seen by the CNA and nurses. PT/OT/Nursing update information to include what assistance is needed for ADL's and transfer. There is also a Kardex tab in POC that has instructions on how to care for the resident. The information continues to be evaluated and updated as the resident's physical or mental ability change. Currently all residents who need mechanical lift transfer are clearly identified with number of staff assistance in place. Random observations on all three shifts are completed to assure that staff are using the appropriate lift and are providing required assistance.

C. An in-service to nursing assistants was completed on 5/30/2022 regarding safety on resident transfer, support, and reinforcement of the importance to follow the resident's plan of care. The DON/designee will conduct a random audit to ensure staff are following the correct care instructions per policy weekly x4 weeks, then monthly x2. Any non-compliance will be corrected timely.

D. Results of audits will be presented to the QAPI committee for review.



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