Nursing Investigation Results -

Pennsylvania Department of Health
REGINA COMMUNITY NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

REGINA COMMUNITY NURSING CENTER
Inspection Results For:
There are 47 surveys for this facility. Please select a date to view the survey results.

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REGINA COMMUNITY NURSING CENTER - 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, and an Abbreviated survey in response to one complaint completed on February 7, 2020, it was determined that Regina Community Nursing Center, 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 related to the Health portion of the survey.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of 43 residents reviewed, resulting in actual harm to the resident who was left unattended on the toilet, fell and sustained a fractured arm (Resident R28).

Findings include:

Review of the facility policy title, "Fall prevention," revised September 2019, revealed that a fall risk assessment is completed by the nurse on all residents at the facility on admission/readmission, quarterly and with a significant change in condition. The facility wide fall prevention program for all residents, includes but is not limited to, orient new residents to their surroundings, use of the call bell system, instructed to summon staff for assistance to get out of bed, wear appropriate shoes with non-skid soles, color coded bracelets for resident to identify level of assistance requested for transfers/ambulation and to place personal items in easy reach of resident.

Review of Resident R28's clinical record revealed that the resident was admitted to the facility on February 10, 2015, with diagnoses including, but not limited to, Dementia (general term to describe symptoms of impairment in memory, communication, and thinking), anxiety, bilateral cataracts, difficulty walking, osteoporosis (a condition in which bones become weak and brittle) and history of falls.

Review of Resident R28's quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated November 5, 2019, indicated that the resident had severe cognitive impairments and required the extensive assistance of one staff person for toileting, personal hygiene and bathing.

Review of Resident R28's, "Fall Risk Evaluation", dated August 14, 2019, and November 5, 2019, revealed that the resident had been assessed by facility staff for her potential for falls. Continued review of Resident R28's Fall Risk Evaluation revealed that on both dates the resident was assessed as a "High Risk for Potential Falls". Further review of the Fall Risk Evaluation document directed staff that, "A prevention protocol should be initiated immediately and documented on the care plan."

Review of Resident R28's care plan for ADL (Activities of Daily Living -refers toileting, bathing, dressing, ambulation, transfer and eating) related to impaired mobility and diagnosis of dementia revised November 12, 2019, revealed that the resident will be washed, appropriately dressed and odor free daily. The interventions included to provide close supervision of resident when in wheelchair. There was no interventions developed in the resident's care plan regarding the level of assistance required during toilet use or the resident's ability to use toilet. Further review of the resident's care plan addressed the problem of frequent urinary incontinence and for the resident to be clean, dry and odor free. The interventions included to wash, pat dry and apply moisture barrier after each episode of incontinence and a scheduled toileting program.

Review of Resident R28's clinical record revealed nurse's progress note dated December 27, 2019, at 6:00 p.m., which stated that, "nurse was called to second floor C-Hall bathroom due to resident falling. Resident was observed sitting on the toilet, following assessment by nurse. Emergency response was called due to resident hitting her head and inability to move right upper extremity. ... Resident was picked up at 6:30 p.m.". The nurse's progress note further stated that the resident was being admitted to the hospital for a fracture (broken bone) of right ulna and radius (two bones of the forearm near the wrist joint), right forehead hematoma (collection of blood underneath the skin), and possible syncopal (fainting) episode after fall.

Review of facility document, "Event Data Collection Worksheet," dated December 28, 2019, related to Resident R28's fall indicated that "CNA (nursing assistant) had resident on toilet in C-hall shower room and went to get soap from other side of room, and resident stood up and attempted to ambulate self and fell. Was found sitting on floor by trash can in bathroom."

Further review of the fall investigation dated December 27, 2019, identified the nursing assistant, as Employee, E4, under the paragraph named "describe incident in full detail including events that led up to the incident." The nursing assistant, Employee E4, stated that, "I put her on the toilet, went to get soap and heard her fall."

Review of the facility hall assignment sheet for each resident updated January 7, 2020, noted that a nursing assistant must stand in front of resident while on the toilet.

Interview with Employee E4, nursing assistant, on January 16, 2020, at approximately 2:50 p.m., revealed that she was unable to provide any further details other than what she had already stated in the "Event Data Collection Worksheet," dated December 28, 2019.

Review of the facility provided report dated on December 28, 2019 and updated January 2, 2020, revealed that the facility instructed the nursing assistant to gather personal care items prior to toileting.

The facility failed to ensure that one resident, identifed as at high risk for falling, received the appropriate supervision while on the toilet, fell and sustained a fractured right arm and a hematoma to the right forehead as a result.

28 Pa Code 211.10(d) Resident care policies

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

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

28 Pa Code 201.18(e)(1) Management
Previously cited 2/13/2019

Plan of Correction - To be completed: 02/28/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

As a result of a risk analysis, additional measures have been put into place in an effort to prevent resident R28 from falling while on the toilet. Education on resident safety and accident free environment will be provided to all staff by a PA Department of Health approved in-service provider. Copies of In-service power point slides will be provided to the regional office. Monthly reviews of incident and accident reports will be conducted x 3 months to determine if there are any trends, environmental or supervision concerns or issues that can be addressed. Deficient findings of the review will be reported to the QAPI committee.

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 review of clinical records, facility documentation, facility policies and procedures, and interviews with staff, it was determined that the facility failed to thoroughly investigate an incident related to a fall, for one of 43 residents reviewed. (Resident R28)

Findings include:

Review of Resident R28's clinical record revealed that the resident was admitted on February 10, 2015, with diagnoses including Dementia without behavioral disturbance (Dementia is a general term to describe symptoms of impairment in memory, communication, and thinking), and age-related Osteoporosis (a condition in which bones become weak and brittle).

Review of nurse's progress note, dated December 27, 2019, at 6:00 p.m., stated that, "nurse was called to second floor C-Hall bathroom due to resident falling. Resident was observed sitting on the toilet, following assessment by nurse. Emergency response was called due to resident hitting her head and inability to move right upper extremity. Vital signs were stable, and resident does not appear to be in any distress. Message was sent to doctor, and POA (Power of Attorney) was notified about incident. Resident was picked up at 6:30 p.m." The nurse's progress note further stated that the resident was being admitted for fracture of right ulna and radius (the breakage of one of the two or both the bones of the forearm right near wrist joint), right forehead hematoma, and possible syncopal (fainting) episode after fall.

Review of hospital documentation revealed a physician's note dated December 31, 2019, which noted, "unclear if the patient actually passed out .... I think it is less likely that a cardiac arrythmia or bradycardia contributed much to the fall. It could have been micturition syncope (the human phenomenon of fainting shortly after or during urination), as she was using the toilet just prior to the fall".

On January 16, 2020, approximately at 10:50 a.m., reviewed the facility documentation named 'Event Data Collection Worksheet', dated December 28, 2019, related to the fall incident of Resident R28, which indicated "CNA (nursing assistant) had resident on toilet in C-hall shower room and went to get soap from other side of room, and resident stood up and attempted to ambulate self and fell. Was found sitting on floor by trash can in bath room".

Further review of the fall investigation dated December 27, 2019, identified the name of the nursing assistant, Employee, E4. under the paragraph named "describe incident in full detail including events that led up to the incident." The nursing assistant, E4, stated that, "I put her on the toilet, went to get soap and heard her fall."

Interview conducted on January 16, 2020, approximately at 2:50 p.m., with nursing assistant, Employee E4, revealed that she was unable to describe any additional details other than what she had already stated in the 'Event Data Collection Worksheet' dated December 28, 2019.

Interview with the Director of Nursing on January 16, 2020, approximately at 2:57 p.m., confirmed that there was no documentation to complete a thorough investigation, to rule out potential resident abuse or neglect, for Resident R 28.

The facility failed to conduct a complete and thorough investigation to rule out potential resident abuse or neglect for one resident.

Plan of Correction - To be completed: 03/09/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
Documentation regarding the accident involving resident R 28 was reviewed to ensure all required pertinent data was obtained to complete the investigation and any appropriate actions will be taken.
All facility investigations of abuse, neglect, exploitation or mistreatment will include but will not be limited to conducting observations of the alleged victim, conduction interviews with the alleged victim, alleged perpetrator, witnesses and others as appropriate, conducting a record review for pertinent information.
Education will be provided on required data to all staff that are responsible for completing an investigation.
Audits will be completed by the DON/ Designee on all incidents and accident reports X 6 weeks to ensure proper steps are taken when abuse, neglect, exploitation or mistreatment is alleged. Deficient findings from the audit will be reported to QAPI committee for review and appropriate action.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Observations:

Based on observation, review of clinical records, review of facility policies and interviews with facility staff, it was determined that the facility failed to develop a comprehensive care plan related to positioning needs and safety alarms for three of 43 resident records reviewed ( Resident R28, Resident R97, and R261).

Findings include:

Review of facility policy," Care Plan Guidelines," dated 9/2010, revealed ".as problems are identified during the care area assessment process, they should be address on the care plan."

Review of the clinical record revealed that Resident R28 was admitted in the facility on February 10, 2015, with diagnoses including Dementia (progressive brain disorder) and Osteoporosis (weak and brittle bones).

A review of the physician's order for Resident R28 dated December 30, 2019, revealed an order for a bed alarm and to check the function and placement every shift and an order for a chair alarm to check the function and placement every shift.

Review of the care plan for Resident R28 revealed that the use of the bed alarm and the chair alarm, including checking the function and placement of the bed and chair alarm every shift were not identified in the comprehensive care plan and that there were no interventions and/or goals planned for this care area.

Interview with the Director of Nursing on January 16, 2020, at approximately 11:17 a.m.,confirmed that the comprehensive care plan for Resident R28 did not include any interventions related to the use of bed and chair alarms.

Review of Resident R97's Quarterly Minimum Data Set (a periodic assessment of resident care needs) dated January 1, 2010 indicated that the resident was totally dependent on 1-2 staff for bed mobility or alternate sleep furniture, transfers, eating and had an impairment to both sides of the upper and lower body. Further review of the clinical record for Resident R97 revealed that the resident had diagnoses including, but not limited to, front temporal dementia (progressive brain disorder), abnormal posture and mobility.

On January 13, 2020 at 3:12 p.m. Resident R97 was observed in the facility's dayroom in a geri chair (is a three-position geriatric recliner chair). The resident was being fed, with the geri-chair in the 45-degree angle but the resident's body was slouched in the chair. Her head was three-quarters down below the head rest and her head was tilted to the left. Resident R97 was observed being fed by a nursing assistant in this slouched position without having her body repositioned.

Observation on January 14, 2020 at 9:05 a.m. revealed a Licensed Nurse administering medication that had been crushed in applesauce via spoon to Resident R97 by mouth. The nurse then gave the resident juice via straw. Throughout the observation, the resident was noted in the same slouched position, without being repositioned.

Interview with the Director of Nursing on January 14, 2020 at 3:00 p.m. confirmed that Resident R97 was often found slouched in the geri-chair and that the facility had failed to develop a comprehensive care plan to meet the proper positional needs for the resident.

A review of the clinical record for Resident R261 revealed that the resident was admitted to the facility on August 2, 2018, with diagnoses including Dementia (progressive degenerative disorder of the brain) with behavioral disturbance.

Review of Resident R261's physician orders dated January 7, 2020, revealed an order for a bed alarm, check function and placement every shift and an order for chair alarm, check function and placement every shift. Review of Resident R261's care plan revealed that the use of the bed alarm and chair alarm, and checking the function and placement of bed alarm and chair alarm every shift were not identified in the resident's comprehensive care plan, and that there were no interventions and/or goals care planned for this care area.

Interview with the Director of Nursing on January 16, 2020, at approximately at 12:54 p.m., confirmed that the findings regarding the comprehensive care plan for R261 were accurate.

The facility failed to develop and implement a comprehensive person centered care plan for Resident R28, Resident R97 and R261.

28 Pa Code 211.11 (a) (b) (c) (d) (e) Resident care plan

28 Pa Code 211.12 (d) (1) (3) (5) Nursing service

28 Pa Code 211.12 (d) (2) Nursing service

Plan of Correction - To be completed: 02/28/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

The Care Plans for Resident R28 and R261 were updated while the survey was in process. Resident R97 no longer resides at the facility.
An Audit of the Care Plans for residents that utilize a geri-chair will be conducted to ensure the residents' positioning needs are addressed. An Audit of the Care Plans will be completed for those residents that utilize a bed and chair alarm to ensure that the Care Plans accurately reflect the use of the devices. DON/ Designee will audit the Care Plans weekly x 4 weeks and report any deficient results to the QAPI committee.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to conduct performance reviews and ensure that each nurse aide received at least twelve hours of annual training.

Findings include:

Review of facility in-service education documentation revealed that no tracking mechanism was available to ensure that all staff received annual training as required.

During an interview on January 15, 2020, at 1:53 p.m., Employee E3, registered nurse, revealed that the facility did not have a system in place to track in-servicing hours completed by nurse aides. Employee E3 confirmed that there was no way of tracking which in-services or how many hours had been completed. Employee E3 also revealed that no performance reviews had been conducted for any nursing staff.

Interview on January 15, 2020, at 2:10 p.m., the Director of Nursing confirmed that the facility does not have a process in place to conduct performance reviews on staff and that the facility does not have any policies related to required in-service education or performance reviews.

The facility failed to conduct performance reviews and ensure that each nurse aide received at least twelve hours of annual training.

28 Pa Code 201.19 Personnel policies and procedures

28 Pa Code 201.20(a) Staff development

Plan of Correction - To be completed: 03/27/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

The facility will develop a performance evaluation for the Nursing Assistants to be completed at least annually. The results of the evaluation will be utilized to conduct any necessary in-services or training to address deficient areas. The facility will be entering into an agreement with an industry popular software vendor to provide and track CNA Training/In-services. Documentation will be maintained on each Nursing Assistant's employment file to reflect their completion of the required annual in-service training. The HR Director / designee will perform monthly audits of personnel files X 3 months to ensure performance evaluations are completed and training is being documented for the Nursing Assistants. Any deficient findings will be reported to the QAPI committee for appropriate action.

§ 201.19 LICENSURE Personnel policies and procedures.:

Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.

Observations:

Based on the review of personnel files and staff interviews, it was determined that the facility failed to provide a job description for four of four employee records reviewed (Employees E8, E9, E10, E11).

Findings include:

Review of Employee E8, E9, E10, E11s' personnel records revealed that Employee E8 was hired as a nursing assistant on September 26, 2019; Employee E9 was hired as a maintenance technician on November 1, 2019; Employee E10 was hired as a Licensed Practical Nurse on November 11, 2019; and Employee E11 was hired as a Registered Nurse on December 4, 2019.

Further review of Employee E8, E9, E10, and E11's personnel record revealed that there were no documentation available to review their job description.

Interview conducted on January 16, 2020, at 10:32 a.m., with the Social Service Coordinator and Human Resources Personal, Employee E12, confirmed that there was no job description available for review since it was not provided Employee E8, E9, E10, and E11.

The facility failed to provide job descriptions to Employees E8, E9, E10, and E11.

28 Pa Code 201.19 Personnel policies and procedures

28 Pa Code 201.20(a) Staff development

Plan of Correction - To be completed: 03/27/2020

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

Employees E8,E11 no longer work at facility. employee E9 and E10 were provided a copy of their respective job descriptions. Facility will make available job description to all current employees. Going forward, a copy will be made available to all newly hired employees during the orientation process. Documentation will be placed in the personnel file of each employee indicating receipt of their job descriptions. The HR Director / designee will perform monthly audits of personnel files X 3 months to ensure performance evaluations are completed and training is being documented for the Nursing Assistants. Any deficient findings will be reported to the QAPI committee for appropriate action

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