Nursing Investigation Results -

Pennsylvania Department of Health
PRESTON RESIDENCE
Patient Care Inspection Results

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PRESTON RESIDENCE
Inspection Results For:

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PRESTON RESIDENCE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on February 16, 2021, it was determined that Preston Residence 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 related to the Health portion of the survey process.




























































 Plan of Correction:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on staff interview, clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an allegation of psychological abuse for one (Resident R2) of two residents reviewed.

Findings include:

Review of facility policy titled, "Resident Abuse", revised on November 2016, revealed "Psychological abuse includes verbal abuse, mental abuse, threats, isolation and any behavior which causes fear in the resident."

Further review of facility abuse policy revealed "All incidents of abuse or suspected abuse will be thoroughly investigated by the facility. The policy further states "The facility will have evidence that all alleged violations are thoroughly investigated."

Review of clinical documentation revealed a Minimum Data Set (MDS) dated December 21, 2020, for Resident (R2) including a Brief Interview for Mental Status (BIMS) with a score of 15, indicating intact cognitive response.

Review of facility documentation revealed a grievance form submitted on December 21, 2020, by Licensed Employee (E1). Report of the incident stated resident reported "she (Resident R2) was reprimanded by her nurse" following a phone call Resident R2 received on December 18, 2020, where she discussed complaints related to her care.

Further review of the grievance form revealed that Licensed Employee (E2) attempted to interview the resident on December 21, 2020, but was unable to complete interview.

Review of Resident R2's clinical documentation revealed the resident was hospitalized from December 21, 2020, until December 23, 2020.

Review of facility documentation revealed that Employee (E2) interviewed Resident R2, and the documentation stated "resident did not want to talk about the incident."

Further review of facility and clinical documentation failed to reveal an investigation was completed.

An interview with the Nursing Home Administrator and the Director of Nursing (DON) on February 16, 2021, at 12:52 p.m. confirmed that the facility did not investigate the allegation of psychological abuse.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical Records




 Plan of Correction - To be completed: 03/15/2021

- Resident R2 no longer resides at the facility
- Implementation of investigation checklist to include question of we're all shift staff interviewed for the alleged event, residents, witnesses, and other residents who may of been effected
- Social Services Coord or Designee will educate all staff by 3/15/21 on signs of abuse and reporting
-Social Services or designee will complete monthly audit of grievance binder to ensure checklist is being used appropriately.
-NHA will review all grienves for satisfactory completion before signing off that grievance was resolved effectively.
- Audit tool will be presented to QAPI committee for review and suggestion


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to administer medications ordered by the physician that resulted in a significant medication error for one of four residents reviewed (Resident R1).

Findings include:

A review of Resident R1's diagnosis list revealed diagnoses of a closed left hip fracture with surgery, essential hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD) (lung disease that blocks airflow), coronary artery disease (narrowing or blockage of coronary arteries) anxiety, and urinary retention (unable to empty all urine from the bladder).

A review of Resident R1's Physician's Order Sheet (POS) revealed orders written on December 22, 2021, for Lovenox (prevention of deep vein and pulmonary embolism) 40 mg/0.4ml, give 1 injection subcutaneously 1 time daily; Metoprolol Succinate (reduces heart rate and blood pressure) 25mg tablet give 1 tablet by mouth 1 time daily hold for heart rate below 60 or SPB below 110; Clopidogrel (blood thinner)75mg, give 1 tablet by mouth daily, and Symbicort (treatment of asthma and chronic obstructive pulmonary disease) 160-4.5mcg inhaler, give 2 puffs orally 2 times daily.

A review of Resident R1's January 2021 Medication Administration Record (MAR) revealed that the Lovenox, Metoprolol Succinate, Clopidogrel and Symbicort, medications were not administered to Resident R1 on January 4, 2021. Further review of the same MAR revealed the medication Lovenox was also not administered on January 6, 2021.

A review of Resident R1's clinical records, nursing progress notes, failed to reveal documentation as to why the medications were not administered on January 4 and 6, 2021. Clinical records review also failed to reveal that the physician was notified of the missed medication doses.

An interview with the Nursing Home Administrator on Feburary 16, 2021, confirmed that medications for Resident R1 on January 4, 2021, at 9:00 a.m and the Lovenox on January 6, 2021 were not given.

An interview with the Director of Nursing (DON) on Feburary 16, 2021, at 12:24 p.m. confirmed that the facility does not have documentation and reason as to why the ordered medications for Resident R1 were omitted. The DON also confirmed that there was no documented evidence that the physician was notified of the missed medication doses.


28 PA Code 201.14(a) Responsibility of licensee

28 PA Code 201.18 (b)(1)(e)(1) Management

28 PA Code 211.5(h)Clinical records

28 PA Code 211.12(d)(1)(5) Nursing Services

28 PA Code 211.12(d)(3) Nursing Services






 Plan of Correction - To be completed: 03/15/2021

Resident R1 no longer resides in the facility
- Agency RN no longer with that agency and staffing agency no longer being used
- DON/Designee will educate all LPN/RN staff about notification and documentation process on medications not given or available by 3/15/21
- Random Chart checks will be done by DON daily for 2 weeks and then bi weekly for 1 month for medication administration accuracy
- Audit tool will be presented to QAPI committee for review and suggestion


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