Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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SAUNDERS HOUSE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a COVID-19 Focused Infection Control Survey and an abbreviated survey in response to two complaints completed on February 17, 2022, it was determined that Saunders House 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.

 Plan of Correction:

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that one of five residents reviewed was free from a physical restraint (Resident R1).

Findings include:

A review of Resident R1's clinical record revealed that the resident was admitted to the facility on July 2, 2020, with diagnoses that included but were not limited to; hemiplegia ( a weakness of one side of the body resulting in loss of motor skills on the affected side), seizure disorder (a range of symptoms caused by abnormal neuronal activity in the brain that can manifest as altered level of consciousness to uncontrolled shaking movements) and anxiety (an emotional state characterized by nervous behavior).

A review of the quarterly Minimum Data Set (MDS-a periodic review of the resident's needs) revealed that the resident had a BIMS (brief interview for mental status) score of 15, indicating that the resident was cognitively intact. The resident was capable of understanding, being understood and making informed decisions regarding her health care needs.

Review of nursing documentation dated September 27, 2021 revealed that the "Resident wanders back and forth from her room to the day room multiple times per day, most times for no reason at all. Is usually easy to redirect. Otherwise, no behavioral concerns." On September 30, 2021 the resident put herself in bed without asking for assistance, "explained safety concerns to resident who expressed understanding at the time."

Review of Social Services documentation dated January 21, 2022 at 3:43 p.m. revealed that the Social Worker was called to front lobby to meet a police officer. The police officer stated that Resident R1 had called 911 emergency Medical services) to say that nursing would not reposition her in the chair.

Review of nursing notes dated January 21, 2022 at 3:45 p.m., noted that "when resident is placed in her geri chair (a large padded chair that reclines back) on day shift it is for safety precautions. When resident is in her wheelchair she frequently goes into her room to attempt to toilet herself and/or get into bed without ever asking for any assistance from staff."

Review of Resident R1's January 2022 physician orders revealed no order for the use of a geri chair recliner. Further review of the clinical record revealed no documented evidence that the resident was assessed for the use of a geri reclining chair and that parameters where established for the use of a geri chair.

An interview with the Director of Nursing, on February 17, 2022, at 1:00 p.m. confirmed that there was no physician order or supporting clinical documentation to justify utilizing a geri chair to restrict the resident's movement.

28 Pa. Code 211.8(a) Use of restraints

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

28 Pa. Code 211.12(d)(3)(5) Nursing services


 Plan of Correction - To be completed: 04/06/2022

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for the purposes of general liability, professional malpractice or any other court proceeding.

Resident R1 has been assessed and parameters have been set for the use of the geri-chair recliner and a physician order has been obtained.

An audit was done for all residents using geri-chair recliners to ensure each is being utilized appropriately and required documentation is in place.

Nursing staff will be provided in-service training on guidelines for the use of geri-chair recliners and the restraint policy.

Random audits will be done weekly by the Unit Managers/RN Supervisors of residents who are utilizing geri-chair recliners to include observation of the resident in the geri-chair recliner and review of medical record for appropriate documentation for the recliners' use.

As part of the Quality Assurance Performance Improvement Program, the results of these audits will be reported monthly by the Director of Nursing/designee to the QAPI Committee for review and recommendation.

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