Pennsylvania Department of Health
 PROVIDENCE POINT HEALTHCARE RESIDENCE
Patient Care Inspection Results

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PROVIDENCE POINT HEALTHCARE RESIDENCE
Inspection Results For:

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PROVIDENCE POINT HEALTHCARE RESIDENCE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Survey, in response to two complaints, completed on July 31, 2024, it was determined that Providence Point Healthcare Residence 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 Regulation as they relate to the Health portion of the survey process.


 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on review of facility policies, resident clinical records, documentation provided by the facility and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in a skin tear requiring a treatment for one of four residents ( Resident R7).

Findings include:

Review of the United States Code of Federal Regulations (CFR), 42 CFR Freedom from Abuse, Neglect, and Exploitation defined neglect as "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress."

Review of facility policy "Preventing Resident Abuse" last reviewed on 5/24, indicated that residents will not be subject to physical, mental, etc. abuse. Annual training of all employees will be conducted to ensure the knowledge of the abuse policy. Policies and procedures have been developed to document the facilities philosophy regarding the elderly. The policies are reviewed and revised as needed to comply with current regulations and standards of care. Close scrutiny of incident reports for targeted residents or trending is completed. The alleged abuser will be informed of the allegation and removed from the area. They will be asked to prepare a statement and may be placed on leave, pending the outcome of the investigation.

Review of the facility policy "Incident/ Event Report," last reviewed on 5/24, indicated that the facility will track the treatment and evaluation of incidents such as skin tears, lacerations, bruises and falls to formulate preventive practices.

Review of the clinical record indicated that Resident R7 was admitted to the facility on 4/22/22, with diagnoses which included dementia with other behavioral disturbances, atrial fibrillation( irregular heart beat), a pacemaker, difficulty walking, prescience of an artificial heart valve prescience of artificial knees and left hip and malnutrition. Review of the Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 6/4/24, indicated the diagnoses remained current.

Review of physician orders indicated Resident R7 requires assistance of two for care provided while she is in bed.

Review of a progress note dated 4/18/24, indicated that Nurse Aide (NA) Employee E 1 told Licensed Practical Nurse (LPN) Employee E2 that "around 5:30 a.m., doing rounds she was turning resident and realized once she turned resident's back towards her, resident arms had been folded and probably pressure caused some shearing resulting in the skin opening. This nurse observed skin opening to left forearm of 5 x 1.5 cm."

Review of an incident report dated 4/18/24, indicated information as above.

Review of a written statement by NA Employee E1 dated 4/18/24, indicated at 5:30 a.m., doing rounds, "I was turning Resident R7 and realized once I turned her back towards me, her arms had been folded and I think the pressure caused some shearing resulting in the tear. I notified the nurse immediately."

Review of a written statement by Registered Nurse Employee E3 dated 4/18/24, indicated, "At 5:30 a.m., during am care, Resident R7 sustained a 5 cm x 1.5 c,m, skin tear." The physician was called and a treatment was obtained. A Summary also on the statement form indicated Resident R7 has dementia with poor safety awareness, and a treatment had been ordered.

During an interview on 7/31/24, at 8:39 a. m., the Director of Nursing (DON) stated that she had "looked into the incident and did not identify it as neglect, but after re- review, she could see how it could be." The DON confirmed that the facility failed to ensure that Resident R7 was free from neglect, which resulted in a skin tear requiring treatment and failed to protect Resident R7 from potential of further neglect/ abuse during the investigation.

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

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

28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(3) Nursing services.


 Plan of Correction - To be completed: 09/20/2024

R7 bed mobility order was verified, staff re-educated on following physician orders. Skin tear is resolved.

A whole house audit will be conducted of all resident transfer orders by the DON/Designee with confirmation of orders in POC for nurse aides.

Education of nursing staff was immediately conducted by DON on preventing resident Abuse and Neglect policy and following physician orders.

A list of Event Categories provided to administrative nursing personnel and shift supervisors by the NHA on definitions of abuse and reporting timeframes and agency requirements.

Relias education was assigned to all nursing staff on Transfers Assist from Wheelchair to Bed, Complete bed bath, Bed Rest Essentials and turning and repositioning in bed.


All incidents/accident event reports and grievances will be audited by the DON/Designee daily x2 weeks, Weekly x4 weeks and monthly x3 months. Audit results will be reviewed at quarterly QA 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 facility policy, facility documents, clinical records, and staff interviews, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of seven residents (Residents R7 and R28).

Findings include:

Review of the facility policy "Preventing Resident Abuse," last reviewed May 2024, with a previous review date of May 2023, indicated that every complaint or allegation of resident abuse or neglect will be immediately reported to the Director of Nursing(DON) by the charge nurse and the DON will notify the Administrator The person receiving the report will make investigation a priority in order to protect the resident and gather data in a timely manner. Incidents and accidents are investigated at the time of the discovery.

Review of the clinical record indicated that Resident R7 was admitted to the facility on 4/22/22, with diagnoses which included dementia with other behavioral disturbances, atrial fibrillation (irregular heart beat), a pacemaker, difficulty walking, prescience of an artificial heart valve prescience of artificial knees and left hip and malnutrition. A review of the Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 6/4/24, indicated the diagnoses remained current.

Review of current physician orders indicated Resident R7 requires assistance of two for care provided while she is in bed.

Review of a progress note dated 4/18/24, indicated that Nurse Aide (NA) Employee E 1 told Licensed Practical Nurse (LPN) Employee E2 that "around 5:30 a.m., doing rounds she was turning resident and realized once she turned resident's back towards her, resident arms had been folded and probably pressure caused some shearing resulting in the skin opening. This nurse observed skin opening to left forearm of 5 x 1.5 cm."

During an interview on 7/31/24, at 8:39 a. m., the Director of Nursing (DON) stated that she had "looked into the incident and did not identify it as neglect." The DON confirmed that the facility failed to ensure that Resident R7 was free from neglect, which resulted in a skin tear requiring treatment.

Review of the clinical record indicated that Resident R28 was admitted to the facility on 4/2/24, with diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, Parkinsonism (tremors, rigidity and unstable posture), anxiety disorder and low back pain. A review of the MDS dated 7/9/24, indicated the diagnoses remained current.

Review of a physician order dated 4/4/24, indicated Resident R28 was to be transferred with assistance of two for safety.

Review of a "Grievance Form" dated 6/9/24, indicated Resident R28's family submitted a concern with staff transferring him from his wheelchair into bed by "lifting" him without a second staff person as ordered.

During an interview on 7/29/24, at 1:56 p.m., the Nursing Home Administrator and DON confirmed that the facility failed to identify and investigate the potential of neglect for Resident R28.

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

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

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


 Plan of Correction - To be completed: 09/20/2024

Resident R7 Event report and statement reviewed. Bed mobility order was verified, staff re-educated on following physician orders. Skin tear is resolved

Resident R28 Grievance reviewed, Statement by the CNA obtained and reviewed. Abuse policy reviewed with nursing staff. Wife notified of outcome and grievance resolved. No negative outcome to the resident.


DON/Designee will read Facility Activity Report in the EHR and review nursing progress notes daily for reportable incidence and confirm there is a correlating Event Report Filed in the EHR and submitted to the DON.

To protect all residents, All staff will be educated by an in-service conducted by the DON/Designee on Incidents and Event Reporting requirements and the importance of reporting events to the DON/Supervisor in a timely fashion.

In order to maintain compliance, the DON/Designee will audit all Incidence and Grievance reports for abuse and neglect and events are submitted via the ERS system timely according to the ERS reporting guidelines. weekly x3 weeks then monthly x3 months
Audit results will be reported at QA Committee Meeting.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 15 residents during the night shift for 13 of 21 days (7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/19, 7/20, 7/21, 7/24, 7/25/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 7/8/24 through 7/28/24, revealed the following nurse aide staffing shortages:

On 7/9, 7/10, and 7/11/24, the census was 38, which required 2.53 NAs during the night shift. Review of the nursing time schedules revealed 2.13, 2.00, and 2.03 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/12/24, the census was 39, which required 2.60 NAs during the night shift. Review of the nursing time schedules revealed 2.03 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/13, 7/14, and 7/15/24, the census was 40, which required 2.67 NAs during the night shift. Review of the nursing time schedules revealed 2.00, 2.09, and 2.00 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/16/24, the census was 39, which required 2.60 NAs during the night shift. Review of the nursing time schedules revealed 1.94 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/19 and 7/20/24, the census was 36, which required 2.40 NAs during the night shift. Review of the nursing time schedules revealed 2.00 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/21/24, the census was 37, which required 2.47 NAs during the night shift. Review of the nursing time schedules revealed 2.00 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/24 and 7/25/24, the census was 36, which required 2.40 NAs during the night shift. Review of the nursing time schedules revealed 2.03 and 2.06 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 7/31/24, at 1:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one nurse aide per 15 residents during the night shift on 13 of 21 days.


 Plan of Correction - To be completed: 09/20/2024

The director of Nursing educated the Staffing Coordinator on PA Code 211.12 as it relates to Staff to resident Ratios and Direct Nursing Care Hours on: 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/19, 7/20, 7/221, 7/24, 7/25/2024.

The staffing coordinator will ensure that the correct number of CNA's are scheduled for each shift (day, evening and night) utilizing the staffing ratio/PPD worksheet.

The facility will continue with bi-weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external cantidates. Offering referral bonuses to attract and retain staff.

The DON/Designee/Scheduling Coordinator will review the monthly schedules that the ratios are being met.

Audits of compliance for meeting the NA ratio will be conducted by the DON/Designee and Scheduling Coordinator weekly for two weeks, then monthly x3 months and reported quarterly thru QAPI.


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