Nursing Investigation Results -

Pennsylvania Department of Health
EMBASSY OF LOYALSOCK
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF LOYALSOCK
Inspection Results For:

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EMBASSY OF LOYALSOCK - 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 April 27, 2022, it was determined that Embassy of Loyalsock 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to ensure an environment free from accident hazards to prevent falls and/or injuries that caused harm for one of six residents reviewed for fall concerns (Resident 2) and implement interventions for one of six residents for fall concerns (Resident 3).

Findings include:

The facility policy entitled " Falls and Fall Risk, Managing," last reviewed January 20, 2022, revealed that in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Clinical record review for Resident 2 revealed nursing documentation dated November 8, 2021, at 2:22 PM that indicated the physical therapist identified a bruise to Resident 2's right flank measuring 19 by 14 centimeters (cm) and right shoulder measuring 4 by 2.5 cm. Review of the facility investigation revealed a temporary nurse aide reported she witnessed Resident 2 ambulating without her walker on November 7, 2021. Resident 2 stumbled and fell hitting her right side on the footboard of the bed. The temporary nurse aide (TNA) did not report this fall until the physical therapist identified the above injuries of unknown origin. Review of the temporary nurse aide statement revealed that she was in the room with Resident 2 when she was getting ready for bed, and she did not know that Resident 2 required supervision. The temporary nurse aide stated she was in Resident 2's bathroom when she witnessed Resident 2 leave her walker by the bed and walk to close to blind and when walking back to her walker Resident 2 stumbled and fell hard on her mattress hitting her right side on the foot of the bed. The TNA indicated that Resident 2 did not complain of pain and continued what she was doing before getting into bed.

Review of Resident 2's MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated November 3, 2021, revealed nursing staff assessed Resident 2 as requiring supervision of one staff member for transferring and walking.

Review of Resident 2's plan of care for her potential risk for falls revealed the facility implemented a chair alarm on June 28, 2021. Review of Resident 2's physician orders revealed the facility ordered a pressure alarm while Resident 2 was in bed on November 17, 2021, and then discontinued this alarm on December 7, 2021.

Nursing documentation dated December 8, 2021, at 8:01 PM revealed Resident 2 was found sitting on the floor leaning up against her dresser and her right leg was externally rotated. The assessment revealed Resident 2 had a small laceration on the right side of her head, and a laceration to her right forearm. Documentation dated December 9, 2021, at 7:14 AM revealed that Resident 2 was transferred to the emergency room and diagnosed with a fracture of her right femur. Resident 2 remained in the hospital until December 15, 2021.

Review of the facility's investigation into Resident 2's December 8, 2021, fall revealed three witness statements relating staff concerns with Resident 2's bed alarm being discontinued on December 7, 2021, due to Resident 2's continued independent ambulation without requesting help. The facility's investigation into Resident 2's fall was not thoroughly completed (predisposing environmental factors, predisposing physiological factors, and predisposing situation factors). The investigation did reveal that "room was clear, resident had shoes on." Interview with the Director of Nursing on April 27, 2022, at 1:48 PM confirmed the facility did not determine where Resident 2 was prior to her fall with fracture and confirmed the investigation did not address Resident 2's physician ordered chair alarm.

Interview with the Director of Nursing on April 27, 2022, at 12:50 PM stated that Resident 2's bed alarm was discontinued because Resident 2 was turning off her bed alarm; however, she was unable to provide any documentation from staff that indicated Resident 2 refused or turned off her bed alarm.

Review of Resident 2's physician orders revealed the facility re-ordered her pressure alarm while she was in bed on December 16, 2021.

Review of Resident 2's physician orders dated January 4, 2022, revealed she ordered Resident 2 to be non-weight bearing to her lower extremity at all times until February 1, 2022.

Nursing documentation dated March 10, 2022, at 1:51 PM revealed the interdisciplinary team reviewed Resident 2's falls and alarms. Documentation revealed the interdisciplinary team reviewed with nursing staff on the unit their recommendation to continue with Resident 2's bed and chair alarms.

Review of Resident 2's MDS dated March 11, 2022, revealed that nursing staff assessed Resident 2 as requiring an extensive assistance of two staff for transfers.

Review of Resident 2's follow up with the orthopedic surgeon on March 15, 2022, revealed that Resident 2 was to continue non weight bearing for eight weeks for continued healing.

Nursing documentation dated April 10, 2022, at 4:15 PM indicated Resident 2 fell out of her chair. Resident 2 was noted to be bleeding from her right frontal scalp area. The registered nurse indicated the area was bleeding heavily, 911 was called, and Resident 2 was transferred to the emergency room. Nursing documentation dated April 10, 2022, at 4:50 PM revealed that an intervention to prevent future falls when Resident 2 returned from the hospital indicated a bed and chair alarm will be added. Documentation dated April 11, 2022, revealed Resident 2 received a stitch to her frontal lobe laceration, and she was noted to have a "goose egg" below the laceration.

Review of the facility's investigation into Resident 2's April 10, 2022, fall did not document Resident 2's physician ordered alarms were in place. The investigation did not mention Resident 2's ordered alarms.

Interview with the Director of Nursing on April 27, 2022, at 1:30 PM confirmed Resident 2's chair alarm was not in place at the time of Resident 2's fall resulting in a scalp laceration on April 10, 2022. The Director of Nursing stated upon interviewing staff after surveyor's questioning, staff confirmed the chair alarm was not in place. She stated that "the staff thought the alarms were discontinued."

The facility failed to implement an intervention, consistent with Resident 2's needs and plan of care to prevent a fall that caused harm.

Clinical record review for Resident 3 revealed a quarterly MDS dated April 8, 2022, which revealed the resident had a BIMS of 3. During the look-back period of seven days, Resident 3 required extensive assistance of two staff for transfers and did not walk during the look-back period. He required extensive assistance of one staff for dressing.

Record review for Resident 3 revealed a care plan dated February 23, 2022, identifying the resident to be at risk for falls related to impaired mobility, confusion with decreased safety awareness, pain, and glaucoma (eye disease causing slow vision loss). An intervention initiated on February 23, 2022, was to ensure the resident was wearing non-skid socks (socks with grippers or shoes) while out of bed.

Clinical record review for Resident 3 revealed a RN progress note dated April 9, 2022, at 11:51 PM indicating that the resident was heard yelling and was found sitting on the floor with his back against the bed, facing the window. He was assessed as having no injuries. He was incontinent at the time and was not wearing non-skid socks.

Review of facility documentation dated April 9, 2022, revealed that the predisposing environment factor into the fall was that the non-skid socks were not in place.

Review of an in-service training record that was initiated April 11, 2022, revealed that education was provided to ensure that Resident 3 wears non-skid socks when in bed.

Resident 3 was incapable of applying non-skid socks independently. The facility failed to implement an intervention, consistent with Resident 3's needs and plan of care to prevent a fall.

During an interview with the Director of Nursing on April 27, 2022, at 2:00 PM findings for Resident 3 were reviewed.

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





 Plan of Correction - To be completed: 05/24/2022

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1.Interdisciplanary team will review residents 2 and 3 plan of care weekly during fall and risk meeting and update as necessary. Education to nursing staff to ensure non-skid socks are on as ordered.

2. DON completed audit of all residents with alarms. Alarm placement and functioning added to care plan, orders, and tasks to be signed off on every shift.

Nursing staff education on new alarm process to add alarms to orders, tasks, Care Plan and to check placement and functioning each shift and sign off in task.

3.DON or designee to educate nursing staff on completing thorough incident reports and witness statements and new alarm process of checking function and signing off each shift.

4. Morning IDT sheet updated to include a place to monitor all incidents to ensure POC was followed, RN assessment completed, new intervention implemented and care plan updated.


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