Pennsylvania Department of Health
WILLOWS OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WILLOWS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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WILLOWS OF PRESBYTERIAN SENIORCARE - 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 July 9, 2024, it was determined that Willows of Presbyterian Senior Care was not in compliance with the 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:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, resident clinical record, facility incident documentation, resident and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per physician's order for one out of eight sampled resident records (Resident R1). This was identified as past non-compliance.

Findings include:

The facility "Abuse" policy dated 2/7/24, indicated that neglect is the failure of the community, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

The facility "Lifting and transferring residents" policy dated 11/20/23, indicated that it is the policy to lift and transfer residents as safely as possible. Mechanical lifts are done by two nursing or therapy personnel. All nursing team members must use the lifting devices as specified in the physician's order.

Review of Resident R1's admission record indicated she was admitted on 4/26/24.

Review of Resident R1's MDS assessment (MDS: Minimum Data Set - a periodic assessment of resident care needs) dated 5/3/24, indicated she had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), hypertension (a condition impacting blood circulation through the heart related to poor pressure), unsteadiness on feet, right artificial knee, and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination).

Review of Resident R1's care plan dated 4/29/24, indicated to transfer Resident R1 with a mechanical lift and assistance with two-persons.

Review of Resident R1's physician order dated 6/26/24, indicated to transfer Resident R1 with assistance with two-persons.

Review of Resident R1's clinical nurse progress note dated 6/27/24, indicated that at 9:00 p.m. Nurse Aide (NA) Employee E1's alerted nurse that Resident R1 sustained a skin tear upon transfer from wheelchair to bed. Resident R1 assessed in bed, clean towel on right lower leg, sustained 12cm skin tear on lateral right lower leg, cleansed and dressing applied.

The facility investigation documents dated 6/28/24, indicated that Resident R1 was interviewed and stated Nurse Aide (NA) Employee E1 came into Resident R1 room, picked up Resident R1 by herself and moved Resident R1 from wheelchair to her bed. Resident R1 stated she bumped her right leg on the bed.

Review of Nurse Aide (NA) Employee E1's personnel record indicated she was oriented to the facility fall prevention program known as "Uprite" on 4/25/24. The program includes a color coded system which indicated the following: Green-independent; Yellow-one-person assistance with transfers/ambulation; Red-two-person assistance with transfers/ambulation.

During an interview on 7/9/24, at 9:20 a.m. Resident R1 stated the following: "I do not remember having a fall. I have very thin skin. The injury to my right leg. Someone put me in bed and I bumped my right leg. I bumped it on the bed. I was in a lot of pain. There was blood on the floor. I think there was one person, I cannot remember."

During an interview on 7/9/24, at 10:43 a.m. Nurse Aide (NA) Employee E1 stated the following:
"On 6/27/24, I went in to help Resident R1 to get ready for bed. She told me she transferred regular. I went to transfer her her on the count of three. I think the wheelchair or the bed split her leg open. I contacted the nurse. The paper I had did not have her transfer status. The nurse came in to assess her leg and it was by me transferring her she scratched her leg on the wheelchair or the bed. Staff have a report paper. I can show you. It will say what her transfer status is. It's a basic report. Her transfer status on that day was blank. I had an interview with the DON, another lady I was speaking to. They told me there was other places I could find the information. I did not have the transfer status information prior to the incident. I asked the resident what her transfer status was and she told me she was able to transfer. I still am not sure what she hit her leg off of. Resident transfer status is discussed during orientation; they explain where things are. Also when I went through my job training."

During an interview on 7/9/24, at 11:01 a.m. Licensed Practical Nurse (LPN) Employee E2 stated the following: "staff are trained about using hoyer lifts. The training includes going over whether they are a one-person or two-person transfer and go by the color codes. Must have two-persons with hoyer lift residents at all time. Follow the protocol at all times for two-person assist. Not one. Make sure when using hoyer lift that arms are crossed for safety purposes. The transfer status information kept is on the outside of the door by resident name. Also, when staff have new admitted resident, the transfer status is set to two-person assist for residents. Then, once they are evaluated, therapy will determined the transfer status. It is a nurse aide flow sheet and is discussed during report."

During an interview on 7/9/24, at 11:05 a.m. Licensed Practical Nurse (LPN) Employee E3 stated the following:
"look on the day planner that everything is correct. I update the planner. And then, look outside the resident room, should be a red dot to indicate a hoyer lift, two-persons with hoyer lift at all times. Staff will know the transfer status and it corresponds with the upright program. Newly hired staff are provided orientation. Day plan is with them at all times. It gives helpful information. Transfer status information is in the physician orders and its on the nurse aide day planner."

On 6/28/24, the facility initiated a plan of correction.

To prevent this from re-occurring,
-Re-education for all staff staring 6/28/24 of proper use of hoyer/mechanical lift
-Re-education for all staff starting 6/28/24 of following physician orders for transferring residents
-Re-education on 7/1/24 with senior nurse aide and nurse aide involved in the incident.
-Facility conducted audits of resident records to ensure that transfer status was updated and current.

To monitor and maintain ongoing compliance:
-Facility conducted audits of protocol for mechanical lift starting 6/28/24.
-The DON/Designee will conduct additional audits of residents transfers completed by staff.

Review of Resident R1's clinical record indicated she was assessed after the incident and was provided a dressing to her right lower extremity.

Review of re-education documentation and audits indicated corrective actions were completed on 7/3/24.

During interviews on 7/9/24, two nurses and four nurse aides interviews determined that corrective actions had taken place.

During an interview on 7/9/24, at 2:02 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per physician's order for Resident R1 as required. This was determined to be past non-compliance.

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

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

28 Pa. Code 211.10(c)(d) Resident Care Policies.

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

Plan of Correction - To be completed: 07/17/2024

Past noncompliance: no plan of correction required.

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