Pennsylvania Department of Health
AVALON PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AVALON PLACE
Inspection Results For:

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AVALON PLACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to an incident completed on February 29, 2024, it was determined that Avalon Place 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.

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 facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received rib fractures that required medical treatment at a hospital for one of one residents reviewed (Resident R1).

Findings include:

Review of the facility policy, "SRC-Safety-17.35 Transfers-ABC", dated 5/12/23, indicated "to assist residents with movement from one surface to another...(1) verify resident's mobility needs...(3) determine the necessary amount of assistance needed in accordance with the plan of care."

Review of the "Job Description Professional CNA (Certified Nurse Assistant)" revealed that the nurse aide will "provide routine resident care and support services in accordance with established policies and procedures..."

Review of Resident R1's clinical record revealed an admission date of 1/18/24, with diagnoses that included but not limited to breathing issues, osteoporosis (decrease in bone mass), high blood pressure, anxiety, depression and repeated falls.

Review of Resident R1's initial Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated 1/21/24, revealed that Resident R1 was alert and oriented and his/her transfer status was an extensive assist, two-person physical assist.

Review of the "Physical Therapy Evaluation- Functional Evaluation" MDS section revealed Resident R1 was a "maximal assist of two for transfers" bed to and from wheelchair.

Review of the "Potential for injury, trauma, falls" care plan revealed Resident R1's transfer status was an assist by two persons. The Kardex (reference document for staff to know provision of care information) revealed Resident R1 was a transfer assist with two persons.

Review of an incident report dated 2/05/24, at 6:48 p.m. revealed that Resident R1 complained of right rib pain and stated that the pain started after being transferred to their chair this morning. The resident had no falls or injuries recently.

Resident R1's statement, written by the Director of Nursing on 2/05/24, revealed that Resident R1 stated the Nurse Aide "bear hugged" the resident to transfer the resident from bed to chair and later in the day was experiencing pain.

Review of a nurse's note dated 2/05/24, at 6:48 p.m., by Licensed Practical Nurse (LPN) Employee E1 revealed that Resident R1 stated that one of the girls was picking Resident R1 up and putting Resident R1 in their chair and Resident R1's ribs hurt. The LPN Employee E1 spoke with the resident and offered Tylenol. After family came in to visit and Resident R1's family member approached the nursing desk and stated that Resident R1 was complaining of rib pain and inquired whether Resident R1 had been checked and requested an x-ray. Nursing note written by LPN Employee E1 at 8:10 p.m stated x-ray in at 7:45 pm. LPN Employee E1 wrote at 10:44 p.m. that at 9:22 p.m. x-ray results revealed that there were minimal buckle fractures of the lateral right third and fifth ribs and no acute fracture on the left rib cage.

Review of a nurse's note dated 2/06/24, at 1:08 p.m. by LPN Employee E2 revealed Resident R1 was medicated for rib pain. Family called into the facility and requested Resident R1 be seen at the emergency room for evaluation and treatment of right rib fractures. Resident R1 was sent to the emergency room at 12:55 p.m.

Review of the hospital "Discharge Summary" report dated 2/06/24, at 5:21 p.m. revealed that Resident R1's reason for the visit was "broken ribs."

Review of nurse's note dated 2/06/24, at 6:54 p.m. by LPN Employee E3 revealed Resident R1 returned to the facility. On the "left side of chest there were mid lateral fractures of the fourth and fifth ribs with mild angulation."

Review of a CT-scan completed at the hospital on 2/06/24, revealed there were subtle non-displaced fracture of the lateral left fourth and fifth ribs.

Review of the "Documentation Supervisor Counseling" form conducted with Nurse Aide (NA) Employee E4, dated 2/07/24, revealed NA Employee E4's statement was that they did not look at the transfer status and that other people transfer Resident R1 with an assist of one.

Review of information submitted by the facility dated 2/12/24, identified that Resident R1 "is identified as a two-person assist with transfers and was transferred by only one staff."

During an interview on 2/28/24, at 9:30 a..m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident R1 alone and that there should have been two staff during the transfer.

The facility failed to provide a safe transfer that resulted in actual harm of rib fractures to Resident R1.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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: 04/01/2024

R1 transfer status was reviewed and plan of care was updated, as indicated. The employee, E4, was reeducated on the requirement to provide a safe transfer as indicated on the Karedex.
At the time of the finding, all staff were verbally reminded the need to follow the care plan and the risk for injury if the care plan is not followed, as indicated.
All RNs, LPNs, and CNAs will be reeducated by the DON/designee regarding the requirement to provide a safe transfer for all residents, by reviewing the transfer status located in the Kardex and following said transfer status.
The Director of Nursing/designee will interview 10 staff members per week for 1 month, and weekly thereafter for 3 months on where to find the resident's correct transfer status. The DON/designee will conduct 10 transfer observations per week for 1 month, and weekly thereafter for 3 months or until substantial compliance is achieved on where to find the resident's correct transfer status to ensure the staff members are providing a safe transfer for all residents, by reviewing the transfer status located in the Kardex and following said transfer status.
All audit results will be reviewed at the Quarterly QA Meeting.

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 facility policy and clinical records and facility documentation, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury for one of one residents reviewed (Resident R1).

Findings include:

Review of a facility policy entitled, "Abuse Neglect Exploitation General Policy" dated 5/12/23, revealed "incidents in which a resident has been injured... should be promptly investigated." The policy indicated a list should be compiled of all witnesses and other persons who have knowledge of the event. Persons considered when interviewing/investigating would include person making the report, individuals alleged to have been involved in the incident, the resident if able and willing to be interviewed, staff on duty working on the unit during the time of the alleged incident, staff on duty working on another unit during the time on the incident that may have information about the incident, staff that may have contact with the resident before or after the period of the alleged incident, residents roommate, family members, visitors, other residents who receive care and services from the individuals alleged to have committed abuse or neglect and witness statements obtained should be filed with the investigation report.

Review of Resident R1's clinical record revealed an admission date of 1/18/24, with diagnoses that included breathing issues, osteoporosis (decrease in bone mass) high blood pressure, anxiety, depression and repeated falls.

Review of a nurse's note dated 2/05/24, at 6:48 p.m. by Licensed Practical Nurse (LPN) Employee E1 revealed that Resident R1 stated that one of the girls was picking Resident R1 up earlier and putting Resident R1 in their chair and Resident R1's ribs hurt. The family was in and requested an x-ray of Resident R1's ribs. Nursing note written by LPN Employee E1 at 10:10 p.m stated x-ray in at 7:45 pm. LPN Employee E1 wrote at 10:44 that at 9:22 p.m. x-ray results revealed there were minimal buckle fractures of the lateral right third and fifth ribs and no acute fracture on the left rib cage.

Review of the Employee Statement Form written on 2/5/24, by the Director of Nursing (DON) identified that Resident R1 was interviewed concerning the transfer incident. Resident R1 stated CNA (certified nurse aide) "bear hugged" the resident to transfer from the bed to chair and later in the day Resident R1 was experiencing pain and then reported it. Resident R1 "unsure of CNA's name who transferred her."

The only other statements in the investigation were written by LPN Employee E1 who Resident R1's pain was reported to and the NA Employee E4 who cared for the resident during the day shift.

Review of Resident R1's clinical record and documentation of incident investigation lacked evidence that a full investigation was completed. The information lacked statements from staff working during the timeframe when the alleged incident occurred in the morning until Resident R1 first complained of pain at 6:00 p.m.

During an interview on 2/28/2024, at 2:20 a.m. the DON confirmed that the investigation completed on Resident R1's incident with injury was incomplete and should have been more thorough.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 04/01/2024

A retrospective review of the incident involving R1 has been conducted. The facility will ensure to fully investigate any incidents with injury.
A retrospective review of incidents that occurred over the last 3 months was conducted to ensure the appropriate steps were taken when investigating an incident and accident, as indicated.
The DON, all RNs and LPNs will be reeducated by the NHA/designee regarding the requirement to complete the incident/accident investigation process, as indicated.
The Director of Nursing will review all incidents with the Administrator 3 times per week for 1 month, and weekly thereafter for 3 months or until substantial compliance is achieved to ensure all incident/accident investigation process is complete, as indicated.
All audit results will be reviewed at the Quarterly QA Meeting.

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