Nursing Investigation Results -

Pennsylvania Department of Health
MANOR AT ST. LUKE VILLAGE, THE
Patient Care Inspection Results

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MANOR AT ST. LUKE VILLAGE, THE
Inspection Results For:

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MANOR AT ST. LUKE VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on March 23, 2021, it was determined that The Manor at St. Luke Village 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:


483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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 a review of clinical records and the facility's abuse prohibition policy and procedure and staff, resident and family interviews it was determined the facility failed to identify and timely report an injury of unknown origin to the State Survey Agency and report the results of the investigation of the the injury of unknown source to rule out abuse, neglect or mistreatment as the cause of the injury sustained by one resident out of five sampled residents (Resident 1).


Findings include:

A review of the facility policy and procedure entitled "Resident Abuse" last revised by the facility September 1, 2016 indicated that It is inherent in the nature and dignity of each resident at The Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services.

A review of Resident 1 was admitted to the facility on October 23, 2020 with diagnoses that included diabetes, anxiety, hypertension. Review of a quarterly Minimum Data Set (MDS assessment -a federally mandated standardized assessment of a resident's abilities and care needs) of Resident 1 dated January 28, 2021, revealed that the resident was cognitively intact.

A review of Resident 1's clinical record revealed documentation dated January 20, 2021, at 5:50 AM, that the resident alerted the nurse at 5:30 AM that her right middle finger was hurting. "Right middle finger is red, warm to the touch, painful upon touch and a yellowy-whitish chalky center is present." The physician ordered Keflex (antibiotic) three times a day for five days and soak in water for 20 minutes three times a day.

There was no documented evidence at the time of the survey ending March 23, 2021, that the facility had conducted an investigation into the origin of Resident 1's injury to her finger.

A review of a physician progress note dated January 21, 2021, revealed that Resident 1 was examined "she is COVID-19 positive, also anemic and she is refusing her iron". There was no evidence that the physician assessed the resident's painful right middle finger during this resident examination or identified a potential cause for the injury.

Resident 1's clinical record revealed documentation dated January 28, 2021, at 3:43 PM which indicated that the physician ordered betadine to the resident's right index finger twice a day for 3 days and Doxycycline (antibiotic) two times a day for 5 days for a diagnosis of cellulitis. There was no indication that an assessment was completed, no further documentation available on this date related to the condition of the resident's finger or the source of the injury.

A review of Resident 1's clinical record revealed documentation dated February 11, 2021, at 3:42 PM that due to the resident's continued complaints of pain of her right index finger, the physician ordered an x-ray of the right hand.

Review of x-ray results dated February 11, 2021, revealed that the resident had a minimally displaced fracture in the base of the third distal phalanx, more likely acute to subacute.

Interview was conducted with Resident 1 on March 23, 2021, at 10:10 AM. Resident 1 stated that her finger was injured while struggling with "that Debbie across the hall" (Resident 2). Resident 1 further stated that Resident 2 came into her room and she "went to pull the tray away from me and I pulled back." According to Resident 1, she yelled loudly at Resident 2 to leave her room.

Interview with the resident's daughter on March 18, 2021, revealed that the resident had reported to her daughter that the injury to her finger was "caused by another patient." The resident relayed to her daughter that another resident (Resident 2) frequently wanders into her room and takes her personal belongings. The resident informed her daughter that Resident 2 had wandered into her room and the residents were involved in a physical struggle during which Resident 1 broke her finger. The resident told her daughter that she had relayed this account to a staff member (last name identified) but that staff member allegedly told the resident not to report the incident since is was "too much paper work."

A review of information submitted by the facility through the time of the survey ending March 23, 2021, revealed that no evidence that the facility had reported anything similar to this allegation to the State Survey Agency.

There was no documented evidence that the facility had identified and acted upon Resident 1's injury of unknown origin or allegation of resident to resident abuse perpetrated by Resident 2 against Resident 1.

Review of Resident 2's clinical record revealed admission to the facility on November 4, 2016 with diagnoses that included dementia with behaviors, major depression, and dysphagia (difficulty swallowing).

Review of an Annual Minimum Data Set (MDS) assessment of Resident 2 dated February 10, 2021, revealed that the resident was severely cognitively impaired.

Review of Resident 2's plan of care initiated October 11, 2018, revealed that the resident is/has potential to be verbally and physically abusive towards staff due to anxiety and mood disorder from known physiological condition with depressive features and updated December 6, 2019 for taking items that don't belong to her. Review of Resident 2's plan of care revealed interventions, which included to keep the resident separated from resident "R.L. Rm 15-1, rm 10A and rm 23B."

Interview with Nursing Home Administrator on March 23, 2021, at approximately 2:30 PM confirmed that the facility did not identify the resident's fractured finger as an injury of unknown origin and timely conduct an investigation to rule out abuse or neglect as the cause of Resident 1's fractured finger and report the results of the investigation to the State Survey Agency.

Refer F610



28 Pa. Code 201.14(a) Responsibility of licensee.

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

28 Pa. Code 201.29 (c)(d) Resident Rights







 Plan of Correction - To be completed: 04/20/2021

1. The incident of Res 1 was reported to the State Surveying Agency on 4/8/21.
2. Residents with incidents and accidents in the last 30 days was reviewed by the DON or designee to ensure identification and timely reporting of an injury of unknown origin to the State Survey Agency as well as reporting of the results of the investigation of the injury of unknown source to rule out abuse, or mistreatment as the cause of the injury.
3. DON or designee will complete re-education with nursing staff on the facility's abuse policy with emphasis placed on investigating injuries of unknown origin. Incident and accident investigations will be reviewed by the Interdisciplinary Team (IDT) during the morning clinical meeting.
4. Quality reviews of incidents and accidents will be completed by DON or designee 5x's/week for 12 weeks to ensure identification and timely reporting of an injury of unknown origin to the State Survey Agency as well as reporting of the results of the investigation of the injury of unknown source to rule out abuse, or mistreatment as the cause of the injury. Findings to be reviewed at QAPI committee and updated as indicated. Quality review schedule to be modified based off of findings.

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 a review of clinical records, the facility's abuse prohibition policy and procedures and information submitted by the facility and staff, resident and family interviews it was determined that the facility failed to timely investigate an injury of unknown to rule out abuse, neglect or mistreatment and protect the resident from the further potential for future abuse for one resident out of five sampled (Resident 1).


Findings included:

A review of the facility policy and procedure entitled "Resident Abuse" last revised by the facility September 1, 2016 indicated that It is inherent in the nature and dignity of each resident at The Company that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services.

A review of Resident 1 was admitted to the facility on October 23, 2020 with diagnoses that included diabetes, anxiety, hypertension. Review of a quarterly Minimum Data Set (MDS assessment -a federally mandated standardized assessment of a resident's abilities and care needs) of Resident 1 dated January 28, 2021, revealed that the resident was cognitively intact.

A review of Resident 1's clinical record revealed documentation dated January 20, 2021, at 5:50 AM, that the resident alerted the nurse at 5:30 AM that her right middle finger was hurting. "Right middle finger is red, warm to the touch, painful upon touch and a yellowy-whitish chalky center is present." The physician ordered Keflex (antibiotic) three times a day for five days and soak in water for 20 minutes three times a day.

There was no documented evidence at the time of the survey ending March 23, 2021, that the facility had conducted an investigation into the origin of Resident 1's injury to her finger.

A review of a physician progress note dated January 21, 2021, revealed that Resident 1 was examined "she is COVID-19 positive, also anemic and she is refusing her iron". There was no evidence that the physician assessed the resident's painful right middle finger during this resident examination or identified a potential cause for the injury.

Resident 1's clinical record revealed documentation dated January 28, 2021, at 3:43 PM which indicated that the physician ordered betadine to the resident's right index finger twice a day for 3 days and Doxycycline (antibiotic) two times a day for 5 days for a diagnosis of cellulitis. There was no indication that an assessment was completed, no further documentation available on this date related to the condition of the resident's finger or the source of the injury.

A review of Resident 1's clinical record revealed documentation dated February 11, 2021, at 3:42 PM that due to the resident's continued complaints of pain of her right index finger, the physician ordered an x-ray of the right hand.

Review of x-ray results dated February 11, 2021, revealed that the resident had a minimally displaced fracture in the base of the third distal phalanx, more likely acute to subacute.

Interview with the resident's daughter on March 18, 2021, revealed that the resident had reported to her daughter that the injury to her finger was "caused by another patient." The resident relayed to her daughter that another resident (Resident 2) frequently wanders into her room and takes her personal belongings. The resident informed her daughter that Resident 2 had wandered into her room and the residents were involved in a physical struggle during which Resident 1 broke her finger. The resident told her daughter that she had relayed this account to a staff member (last name identified) but that staff member allegedly told the resident not to report the incident since is was "too much paper work."

Interview was conducted with Resident 1 on March 23, 2021, at 10:10 AM. Resident 1 stated that her finger was injured while struggling with "that Debbie across the hall" (Resident 2). Resident 1 further stated that Resident 2 came into her room and she "went to pull the tray away from me and I pulled back." According to Resident 1, she yelled loudly at Resident 2 to leave her room.

There was no documented evidence that the facility had acted upon Resident 1's alleged account of the source of the resident's injury and had investigated the allegation of resident to resident abuse perpetrated by Resident 2 against Resident 1.

The facility neither reported to the State Survey Agency, the allegation/injury of unknown origin nor investigated the injury of unknown source as of the time of the survey ending March 23, 2021.

Review of Resident 2's clinical record revealed admission to the facility on November 4, 2016 with diagnoses that included dementia with behaviors, major depression, and dysphagia (difficulty swallowing).

Review of an Annual Minimum Data Set (MDS) assessment of Resident 2 dated February 10, 2021, revealed that the resident was severely cognitively impaired.

Review of Resident 2's plan of care initiated October 11, 2018, revealed that the resident is/has potential to be verbally and physically abusive towards staff due to anxiety and mood disorder from known physiological condition with depressive features and updated December 6, 2019 for taking items that don't belong to her. Review of Resident 2's plan of care revealed interventions, which included to keep the resident separated from resident "R.L. Rm 15-1, rm 10A and rm 23B."

A review of information dated March 25, 2021, submitted by the facility revealed that on March 23, 2021, at approximately 3:45 PM, Resident 5 reported to the facility that Resident 2 had "punched her in the face." According to the reported event, there were no witnesses to the altercation.

Interview with Nursing Home Administrator on March 23, 2021, at approximately 2:30 PM confirmed that the facility did not conduct an investigation to rule out abuse or neglect as the cause of Resident 1's fractured finger upon identification of the injury of unknown origin on January 20, 2021. The NHA verified that the altercation between Resident 1 and 2, which Resident 1 reported to the surveyor and her daughter had caused the injury had not been identified/reported or investigated. Following Resident 1's fractured finger the resident alleged occurred during an altercation with Resident 2 during January 2021, on March 23, 2021, Resident 1 alleged that Resident 2 had punched her in the face.




28 Pa. Code 201.14(a) Responsibility of licensee.

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

28 Pa. Code 201.29 (c)(d) Resident Rights






 Plan of Correction - To be completed: 04/20/2021

1. The injury investigation for Res 1 was completed on 3/23/2021.
2. Residents with incidents and accidents in the last 30 days was reviewed by the DON or designee to ensure timely investigations of injury of unknown origin to rule out abuse, neglect or mistreatment.
3. DON or designee will complete re-education with nursing staff on the facility's Incident and Accident Investigation policy. Incident and accident investigations will be reviewed by the Interdisciplinary Team (IDT) during the morning clinical meeting.
4. Quality reviews of incidents and accidents will be completed by DON or designee 5x's/week for 12 weeks to ensure timely investigations of injury of unknown origin to rule out abuse, neglect or mistreatment. Findings to be reviewed at QAPI committee and updated as indicated. Quality review schedule to be modified based off of findings.

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 resident and staff interviews it was determined that the facility failed to demonstrate that licensed and professional nursing staff and consistently monitored and documented the status of a resident's injury according to professional standards of nursing practice for one resident out of five sampled (Resident 1).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.


A review of Resident 1 was admitted to the facility on October 23, 2020 with diagnoses that included diabetes, anxiety, hypertension.

Review of a quarterly Minimum Data Set (MDS assessment - federally mandated standardized assessment of a resident's abilities and care needs) of Resident 1 dated January 28, 2021, revealed that the resident was cognitively intact.

Clinical record documentation dated January 20, 2021, at 5:50 AM revealed that the resident alerted the nurse at 5:30 AM that her right middle finger was hurting. Nursing noted that the resident's "Right middle finger is red, warm to the touch, painful upon touch and a yellowy-whitish chalky center is present." The physician ordered Keflex (antibiotic) three times a day for five days and soak in water for 20 minutes three times a day.

A review of a physician progress note dated January 21, 2021, revealed that Resident 1 was examined. The physician noted "she is COVID-19 positive, also anemic and she is refusing her iron." There was no documented evidence that the physician had assessed the resident's painful right middle finger during this resident examination.

Nursing documentation dated January 28, 2021, at 3:43 PM, noted that the physician ordered betadine to the resident's right index finger twice a day for 3 days and Doxycycline (antibiotic) two times a day for 5 days for a diagnosis of cellulitis. There was no documented evidence of a nursing assessment of the resident's finger prompting this treatment change. There was no nursing documentation available on this date related to the resident's finger or why additional antibiotic therapy was required.

There was no documentation that the facility's licensed and professional nursing staff had consistently monitored and assessed the status of the resident's finger to timely identify response to treatment, the potential need for treatment changes and healing progress or worsening.

On February 11, 2021, the physician ordered an x-ray of Resident 1's right hand due to the resident's complaints of pain. Documentation in the resident's clinical record failed to provide a nursing assessment of the resident's hand/finger prompting the order for the x-ray.

Review of x-ray results dated February 11, 2021, revealed that the resident had a minimally displaced fracture in the base of the third distal phalanx, more likely acute to subacute. The physician ordered a splint to be applied to the resident's finger.

Nursing documentation in Resident 1's clinical record dated February 15, 2021, at 11:02 AM revealed that the resident had refused to use the splint as ordered. A physician order was received to tape the right index finger with the right middle finger. There was no clinical nursing documentation that an assessment of the resident's finger was completed at this time due to the resident's refusal to wear the splint or use of the tape as an alternate treatment. .

Interview with the Nursing Home Administrator on March 23, 2021, at approximately 1:30 PM confirmed there was no clinical nursing documentation to demonstrate that the facility's licensed and professional nursing staff had consistently monitored and documented the status and condition of Resident 1's hand/finger according to professional standards of nursing practice.


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

28 Pa. Code 211.5(f)(g)(h) Clinical records



 Plan of Correction - To be completed: 04/20/2021

1. Res 1's had was assessed by nursing staff.
2. Residents with a change in condition in the last week was reviewed by the DON or designee to ensure monitoring of resident's status is completed as indicated.
3. DON or designee will re-educate the nursing staff on the facility's 24 hour Report and the Change in Condition policies with emphasis placed on monitoring of resident's status is completed as indicated.
4. Quality reviews of monitoring of resident status will be completed by DON or designee 5x's/week for 12 weeks to ensure consistent monitoring and documenting of the status of a resident's injury according to professional standards of nursing practice. Findings to be reviewed at QAPI committee and updated as indicated. Quality review schedule to be modified based off of findings.


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