Nursing Investigation Results -

Pennsylvania Department of Health
MORAVIAN VILLAGE OF BETHLEHEM
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MORAVIAN VILLAGE OF BETHLEHEM
Inspection Results For:

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MORAVIAN VILLAGE OF BETHLEHEM - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed June 30, 2022, it was determined that Moravian Village of Bethlehem, 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 the Health portion of the survey.










 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 facility policy review, review of incident reports, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 16 sampled residents (Resident 4)

Findings include:

Review of the facility policy entitled " Abuse Investigations", dated January 31, 2022, revealed that all reports of resident abuse, neglect and injuries of unknown source were to be promptly and thoroughly investigated by facility management. The investigation was to include interviews from staff members on all shifts who had contact with the resident during the period of the alleged incident.

Clinical record review revealed that Resident 4 was admitted to the facility on March 25, 2022, and had diagnoses that included Alzheimer's disease and dementia. The Minimum Data Set assessment dated March 28, 2022, indicated that the resident had memory impairment and required extensive assistance with activities of daily living. Review of the current care plan identified the resident was at risk for impaired skin integrity. On May 2, 2022, a nurse noted that the resident was observed with a new bruise to the right side of her chin and right lower lip (appeared as a linear) shape and that the cause of the bruise was unknown/unwitnessed.

Review of the incident report dated May 2, 2022, revealed that the resident had a new alteration in skin integrity. There was no documented evidence that staff members from all shifts who had contact with the resident duing the period of the alleged incident had been interviewed in order to rule out abuse. In an interview on June 30, 2022, at 10:09 a.m., RN1 stated that the facility had not obtained written witness statements and that there was no documented evidence that staff members who had contact with the resident had been interviewed to rule out abuse as per facility policy.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.10(d) Resident care policies

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













 Plan of Correction - To be completed: 08/15/2022

- Documentation of the investigation is being gathered. Resident was assessed and has no remaining ill effects from the bruise.

- Any resident with an injury of unknown origin will have an investigation documented to determine the cause of the injury.

- The Abuse Investigation Policy shall be reviewed for completeness and clarity of intent. The Policy shall be reviewed with the staff who conduct investigations into allegations of abuse. The Resident Safety Committee shall audit all incidents of injury of unknown origin to verify a complete investigation was conducted and documented.

- The Resident Safety Committee will audit incident reports for resident with injuries of unknown origin. Audits will be done weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: August 15, 2022.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to assess and document the status of a pressure ulcer per facility policy for one of three sampled residents. (Resident 22)

Findings include:

Review of the facility policy entitled "Pressure Ulcer Prevention and Management of Skin Integrity" dated January 31, 2022, revealed that skin integrity and/or conditions affecting the resident's skin must be documented at least once every seven days, the pressure of skin breakdown/abnormal skin appearance will be documented weekly, and interventions and progress toward outcome will have documentation at least weekly.

Clinical record review revealed that Resident 22 was admitted on May 17, 2022 with diagnoses that included dementia, history of transient ischemic attack (brief stroke like attack), and congestive heart failure. Review of the Minimum Data Set assessment dated May 25, 2022, revealed the resident had cognitive impairments, and required extensive assistance with activities of daily living including bed mobility, transferring, and personal hygiene. Review of a nurse's note dated May 30, 2022, revealed the resident developed areas to his buttocks, classified as deep tissue pressure injuries. There was no documented evidence that Resident 22's pressure ulcers were assessed and documented per facility policy after June 6, 2022 until June 27, 2022.

In an interview on June 30, 2022 at 10:02 a.m., the Director of Nursing confirmed there is no documentation of weekly pressure ulcer assessment and documentation per facility policy.

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

28 Pa. Code 211.5(f) Clinical records.



 Plan of Correction - To be completed: 08/15/2022

- The Pressure injury for Resident 22 has been resolved.

- Any resident with a pressure injury shall be reviewed for a wound assessment and proper documentation according to the Pressure Ulcer Prevention and Management of Skin Integrity policy.

- The Pressure Ulcer Prevention and Management of Skin Integrity Policy shall be reviewed and updated as necessary. Nurses will be educated on the Pressure Ulcer Prevention and Management of Skin Integrity Policy and audits will be conducted to verify staff understanding and compliance.

- Nursing management will audit wound assessments and treatments documentation for compliance with our Pressure Ulcer Prevention and Management of Skin Integrity Policy. Audits will be done weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: August 15th, 2022.


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 and review of incident reports, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of four sampled residents who were at risk for falls. (Resident 36)

Findings include:

Clinical record review revealed that Resident 36 was admitted to the facility on February 25, 2022, and had diagnoses that included dementia, insomnia, and spinal stenosis. The Minimum Data Set assessment dated February 28, 2022, indicated that the resident had memory impairment, and required a one person assist for transfers The assessment further indicated that she was not steady moving from a seated to a standing position, she was not steady walking and had a history of falls. Review of the current care plan identified the resident was at risk for falls. Review of a fall risk evaluation dated March 31, 2022, revealed that the resident had a history of falls, she was disoriented, occasionally incontinent and had poor safety awareness due to taking risks. Review of a second fall risk evaluation dated June 23, 2022, revealed that the resident was disoriented, was frequently incontinent, lacked safety awareness, and had problems walking even with a device.

Review of nursing documentation and incident reports revealed that Resident 36 had fallen 13 times between February 26, 2022, through June 29, 2022. Most of the falls occurred in her room. Six of the falls were between 5:00 p.m., and 11:00 p.m., four of the falls were between 12:00 a.m., and 2:00 a.m.

On February 26, 2022, a nurse noted that the resident was extremely confused and had gotten out of bed several times. Review of an incident report dated February 26, 2022, at 8:00 p.m., revealed that the resident had been found on the floor in her room. On April 15, 2022, a nurse noted that the resident had gotten up repeatedly from her bed and was combative with staff. Review of incident reports dated April 16, 2022, and April 26, 2022, revealed that the resident had additional falls. A nurse noted on April 26, 2022, that the resident had been exit seeking, was confused and had been pacing the hallway. Review of incident reports revealed that the resident fell again on May 24, 2022, and May 29, 2022. On June 8, 2022, a nurse noted that the resident gets up unassisted in her room. Review of incident reports dated June 8, 11, 13, 23, and 24, 2022, revealed that the resident had fallen five more times. Review of an incident report dated June 29, 2022, revealed that at 12:30 a.m., the resident had an unwitnessed fall in her room requiring a hospital evaluation.

There was no documented evidence that the facility had evaluated the need for increased supervision in order to prevent falls.

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





 Plan of Correction - To be completed: 08/15/2022

- Resident 36 was assessed and has no more residual effects from the fall. The fall interventions for the resident will be reviewed and amended to include options for varying levels of increased monitoring.

- The Resident Safety Committee shall review the interventions implemented for residents with recent falls for appropriateness and the consideration of increased Supervision/monitoring.

- The Falls and Falls Rick, Managing Policy shall be reviewed for the inclusion of supervision/monitoring considerations and updated as necessary. The nurses will be educated on the Policy. Audits will be conducted to verify the staff understanding and compliance.

- The Resident Safety Committee will audit incidents reports for appropriate interventions weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: August 15, 2022.



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