Nursing Investigation Results -

Pennsylvania Department of Health
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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QUARRYVILLE PRESBYTERIAN RETIREMENT COMMUNITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey and one complaint investigation survey, completed on October 4, 2019, it was determined that Quarryville Presbyterian Retirement Community was not in compliance with the following requirements of 42 CFR 483 Subpart B, requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Guidelines, for the health portion of the survey.





 Plan of Correction:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:


Based on observations, review of activity log and staff interview, it was determined that the facility failed to provide an activity program that met the needs and interests of all residents and in accordance with care planned interventions for three of three residents reviewed (Resident #28, # 67, and Resident #75).

Findings Include:

Observation on October 1, 2019 approximately 1:20 p.m. to 2:30 p.m. of the Garden West unit revealed residents in living room with the television turned on or in their rooms resting. Further observation of Garden West unit (skilled nursing memory supportive unit) on October 2, 2019 approximately 9:00-10:30 p.m. revealed residents in the living room observing television programming.

Review of Resident #28's Quarterly MDS (minimum Data Set -periodic assessment of resident needs) dated July 26, 2019 identified the resident with a BIMS (Brief interview of mental status) score of 5 which places the resident as cognitively impaired.

Review of Resident #28's care plan, initiated November 2018, revealed areas of interest identified for resident as one to one visits, crafts, cooking, entertainment, exercise, spiritual activities, and sensory stimulation activities.

Review of Resident #28's activity logs from August 1, 2019 to September 30, 2019 revealed that the resident participated in watching television/newspaper twenty-two times in the month of August 2019 and twenty times in the month of September 2019. Further review of activity logs revealed resident attended bible study/hymn sing 11 times in the month of August and 6 times in the month of September 2019. Additional activities of Bingo/Movies/Music programs that resident attended were noted to be twelve times in August 2019 and twenty-six times during the month of September 2019.

Further review of Resident #28's activity logs revealed that from August 1, 2019 through September 30, 2019 there were sixteen days without any documented activities.

Review of Resident #67's clinical record revealed diagnoses including but not limited to following: Dementia (Irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability); and Sensorineural hearing loss (damage caused to the nerve fibers in the inner ear; characterized by difficulty picking out words against background noise).

Review of Resident's Admission MDS assessment dated August 8, 2019 identified the resident with a BIMS (Brief interview of mental status) score of 3 which places the resident as cognitively impaired.

Review of Resident #67's care plan goal for activities, initiated August 2019, revealed activities of choice noted areas of interest as exercise, musical entertainment, spiritual programs, romance novels, and being off unit with supervision.

Review of Resident #67's activity logs from August 2019 through September 2019 revealed eight days without activity participation or refusal from admission of August 8, through August 31, 2019 and nine days without activity participation or refusal from September 1, through September 30, 2019.

Further review of Resident #67's activity logs revealed twelve times the only activity documented was Newspaper/Television during the month of August and thirteen times during the month of September 2019.

Review of Resident #75's Quarterly MDS Assessment dated August 27, 2019 revealed in Section C (Cognitive Patterns) revealed resident is severely cognitively impaired.

Review of Resident #75's activity care plan, initiated March 2019, revealed
activities of choice were entertainment, spiritual groups, live piano music, exercise, and volunteers for visits as tolerated/desired.

Review of Resident #75's activity logs from August 2019 through September 31, 2019 revealed that there were nine days without any documented activity participation in August 2019 and eight days in September 2019 without any documented activity participation.

Further review of Resident #75's activity logs revealed that for the month of August 2019 there were twelve days that television/newspaper activity was identified as only documented activity and six times in September 2019 that television/newspaper activity noted as only activity recorded.

Interview on October 3, 2019 at approximately 2:50 p.m. with the Nursing Home Administrator and non-licensed employee E3 when the above information was presented and indicated the activities were not representative of individual preferences or areas of interest.

28 Pa Code 201.29(j) Resident Rights

28 Pa Code 211.10(d) Resident care policies

















 Plan of Correction - To be completed: 11/30/2019

Activities admission assessment has been changed to capture a broader range of activities and interests of the residents prior to admission into the facility, so that an activities program can be designed specific to each resident's likes and interests. The electronic health record, Matrix Care, has been reformatted to assist staff with documentation on resident activities. The staff can now indicate when activities were offered and if those activities were performed or declined. A more personalized range of activities has been added to the activities schedule and available to residents on both one on one and in group settings. Staff will be in-serviced on documenting all aspects of resident activities to ensure residents are engaged with their needs and interests. The activities director and/ or designee will reassess all residents to ensure their care plan reflects a personalized activities program. The activities director will randomly audit resident charts to ensure residents likes, interests, and personalized activities are being offered and residents are engaged to meet their psychosocial needs until three months or compliance are met. The results of these audits will be shared and discussed during the QAPI committee meeting.
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 the facility failed to timely complete physician order for one of 18 residents reviewed (Resident 68)

Findings Include:

Review of Resident 68's physician orders revealed an order dated September 10, 2019 for a CMP (Complete Metabolic Panel- blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function), CBC (Complete Blood Cell Count- blood panel that gives information about the cells in a patient's blood), and a TSH (thyroid stimulating Hormone- measures how much of this hormone is in your blood to determine thyroid health).

Review of the Lab results for Resident 68 revealed these labs ordered on September 10, 2019 were not completed until September 17, 2019. Further review of the labs revealed the resident had a Hemoglobin of 6.8 (red protein responsible for transporting oxygen in the blood, normal level is 13.5 to 17.5).

Review of a nursing Progress note dated September 17, 2019 at 5:20 p.m. states "Supervisor made this nurse aware of Hemoglobin 6.8. Wife and Son updated. Son requested that resident be sent to the ER." Further review of the nursing progress notes revealed an entry on September 17, 2019 at 11:02 p.m. stating "Resident admitted with infection and low hemoglobin".

Further review of resident 68's clinical record gave no clinical reason for completing the lab work one week after it was ordered by the physician.

Interview with the Director of Nursing on October 4, 2019 at 10:30 a.m. confirmed there was a delay in completing the physician order on September 10, 2019 for lab work for Resident 68.

28 PA Code: 211.5 (f) Clinical records

28 PA Code: 211.12 (d)(1)(5) Nursing services
Previously cited 10/26/2019






 Plan of Correction - To be completed: 11/15/2019

Nurse who failed to schedule lab order in timely manner educated on policy and practice. The lab draw was taken on the 17th of September and results obtained. Policy reviewed with nursing staff to ensure lab orders are followed in a timely manner or as specified by the doctor. All lab orders for the month of October 2019 will be audited to ensure doctor's orders are followed in a timely manner by D.O.N. and/or designee. D.O.N. or designee will randomly audit lab orders until compliance threshold is met for three months. Findings of audits will be shared in QAPI committee meeting.
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 upon review of facility policy and procedure and clinical record review, it was determined that the facility failed to ensure interventions were in place for the prevention of pressure ulcers for one of three pressure ulcers reviewed. (Resident #17)

Findings include:

Review of facility policy and procedure titled "Skin Integrity - Preventative Care", revised February 2019 revealed "float heels for resident who are unable to reposition themselves; bed cradle/heel boots as necessary."

Review of Resident #17's clinical record revealed diagnoses including peripheral vascular disease (PVD - poor circulation of the extremities), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle).

Review of Resident #17's Quarterly Minimum Data Set Assessment (MDS - periodic assessment of resident needs) dated April 18, 2019 revealed a Brief Interview for Mental Status Score of 3 indicating severe cognitive impairment.

Further review of Resident #17's Quarterly MDS revealed Resident #17 required the extensive assistance of two staff persons for bed mobility and transfer and indicated Resident #17 is at risk for pressure ulcer injury.

Review of Resident #17's Braden Scale for Predicting Pressure Sore Risk dated April 12, 2019 revealed a score of 12 which indicated Resident #17 was at risk for pressure ulcer development.

Review of Resident #17's April 28, 2019 progress notes revealed Resident #17 was noted to have a fluid filled blister on the left heel.

Review of Resident #17's Skin/Wound Tracking Report dated April 29, 2019 revealed Resident #17 had a serous filled blister on the left heel which measured 3.0 centimeters (cm) x 4.0 c.m.

Review of Resident #17's Skin Evaluation Form dated April 29, 2019 revealed "Resident with serous [blood tinged] filled blister on left heel which was documented on 4/28/19. Area assessed and intact serous filled blister noted on left inner heel. Area measures 3.0 x 4.0."

Review of Resident #17's Skin Evaluation Form dated May 6, 2019 revealed "Serous filled blister on left heel now blood filled. Area will now be considered a DTI [deep tissue injury]. Area measures 3.0 x 4.0. Resident denies pain to area. Surrounding skin very dry and blanchable. Resident is using heels off pillow to elevate and relieve pressure to b/l [bilateral] heels."

Review of Resident #17's Skin Evaluation Form dated May 13, 2019 revealed "Left heel DTI now with dry stable eschar [dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed]. Area measures 3.0 x 4.0. Area now considered unstageable."

Review of Resident #17's active plan of care revealed the intervention of off-load heels when in bed was initiated on April 29, 2019, one day after the wound was identified.

Further review of Resident #17's active plan of care revealed that on December 29, 2016 an intervention of instructing and encouraging resident to off-load heels was put into place.

Further review of Resident #17's active plan of care failed to reveal that the resident's care plan was updated to reflect Resident #17's current cognitive status regarding the effectiveness of instruction or encouragement regarding the use of off-load heels and further failed to reveal any further interventions to prevent the development of pressure ulcers to the heels.

Interview with the Nursing Home Administrator and Director of Nursing on October 4, 2019 at approximately 1:00 p.m. confirmed that the off-load heels intervention was not put into place until after the heel blister was discovered and further confirmed that no further interventions were in place to prevent the development of pressure ulcers to the resident's heels.


28 Pa. Code 211.5(f) Clinical Record

28 Pa. Code 211.10(c) Resident Care Policies

28 Pa. Code 211.10(d) Resident Care Policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services









 Plan of Correction - To be completed: 11/30/2019

Resident #17 care plan updated to reflect current cognitive status. Staff will document skin interventions per care plan on TAR and EMR. A.D.O.N. or designee will review residents with cognitive care plan to ensure approaches are reflective of current cognitive status. The facility will develop a Braden Scale intervention guide to ensure the care plans are accurate and designed to prevent skin breakdown. Interventions put in place to prevent skin breakdown on residents at risk will be added to the TAR or MAR, where necessary, so staff can accurately document when interventions were performed. D.O.N. and/ or designee will audit all current residents care plans to ensure proper interventions are put in place. D.O.N. and/ or designee will randomly audit resident care plans to ensure compliance threshold is met for three months. Nursing staff will be in-serviced on new practices and policies put in place. Results of the random audits will be shared with QAPI committee meeting.

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