Nursing Investigation Results -

Pennsylvania Department of Health
WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WYNDMOOR HILLS REHABILITATION AND NURSING CENTER
Inspection Results For:
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WYNDMOOR HILLS REHABILITATION AND NURSING CENTER - 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 November 20, 2019, it was determined that Wyndmoor Hills Health Care and Rehabilitation Center, 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 related to the health portion of the survey process.

Plan of Correction:

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 facility policies, facility documentation,review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct thorough investigations related to potential resident abuse and/or neglect reported to the facility for one of three residents reviewed (Resident R1).

Findings include:

Review of facility policy, "Abuse Investigation and Reporting" dated revised July 2019, revealed that facility investigations will include interviews with any witnesses to the incident, interviews with staff members from all shifts who have had contact with the resident during the period of the alleged incident, interviews with other residents and review of all events leading up to the alleged incident.

Clinical record review for Resident R1 revealed an admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 6, 2019, which indicated that the resident was admitted to the facility on October 30, 2019, cognitively intact and required the physical assistance of one staff person for toileting, hygiene, dressing and bathing.

Interview with Resident R1 on November 20, 2019, at 9:10 a.m., revealed that the resident sometimes has to wait more than 20 minutes to have her callbell answered when she needs assistance with the bathroom and that she is left to sit on the toilet too long.

Review of facility documentation, "Concern Form" dated November 4, 2019, revealed that Resident R1 "was washed yesterday but was not dried off and had to wait over 45 minutes dripping wet before anyone came to get her dressed, she states that she yelled because the callbell was not in reach but no one came for a long time."

Review of another "Concern Form" dated November 5, 2019, revealed that Resident R1 was "made to sit half-clothed, wet and cold by the door for extended periods of time, made to sit with diaper around ankles for extended time, [and] treated with physical aggression i.e. pushed during 4:00 a.m. changing." The Concern Form indicated that the concern was resolved November 8, 2019.

Continued review of facility documentation related to the above Concern Forms revealed that there were no interviews with staff or witness statements available for review.

Interview with the Director of Nursing (DON) on November 20, 2019, at 12:00 p.m. confirmed that she did not interview the staff member who provided Resident R1 with a bath on November 3, 2019, or obtain a witness statement. The DON also confirmed that that she did not interview or obtain a witness statement from the night shift staff member who provided toileting at 4:00 a.m. The DON stated that she considers an allegation of "pushing" as an allegation of abuse. Further interview at 2:15 p.m., the DON reported that the facility has cameras installed in the hallways, that the facility is capable of reviewing camera footage to conduct investigations and confirmed that no camera footage was reviewed related to the allegations from November 4th and 5th, 2019.

The facility failed to conduct thorough investigations to rule out the potential for abuse and neglect in response to allegations reported to the facility.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 4/6/19

28 Pa. Code 201.29(a) Resident rights
Previously cited 4/6/19

Plan of Correction - To be completed: 01/10/2020

1.Resident R-1 Concern form re-opened and investigation thoroughly completed with witness statements
2. Concern forms reviewed to identify any other possible abuse allegations, to assure full investigations were completed if needed. Call bell audits and cameras reviewed to identify any prolonged answering of bells.
3. DON and Social Services re-educated on the concern form process. Concern forms will be submitted to social services daily, in which log is created. An audit will be completed weekly by DON and submitted to Nursing Home Administrator. Random call bell audits will be completed weekly and submitted to Nursing Home Administrator. Concern Form, and Call Bell audits will be reviewed monthly in Quality Assurance Performance Improvement Program.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care that meet professional standards of quality care related to toileting for one of three residents reviewed (Resident R1).

Findings include:

Clinical record review for Resident R1 revealed an admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 6, 2019, which indicated that the resident was admitted to the facility on October 30, 2019, cognitively intact and required the physical assistance of one staff person for toileting.

Review of Occupational Therapy notes revealed that Resident R1 was evaluated on October 31, 2019, and was determined to require supervision or touching assistance with toileting transfers.

Review of Resident R1' s care plan, dated initiated October 31, 2019, revealed that the resident required assistance with ADL (activities of daily living) functions and that the resident required, "Transfers: One assist with transfers, Dressing: One assist, Eating: Set up only [and] Mobility: Walks/wheels only with physical assistance."

Continued review of Resident R1' s care plan revealed that the resident had a colostomy (a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall) and included interventions to monitor the skin and stoma and to provide ostomy care daily and as needed.

Review of the nurse aide Kardex, dated as printed on November 20, 2019, indicated to provide "one assist with transfers" and to "monitor skin around stoma for irritation."

Interview on November 20, 2019, at 9:10 a.m., Resident R1 stated that she sometimes has to wait too long for assistance to go to the bathroom and that staff only empty her colostomy when she asks. The resident further indicated that staff do not empty her colostomy every shift, that it gets full frequently, leaks, comes off, spills stool on her and that she needs assistance with emptying it.

Interview on November 20, 2019, at 11:00 a.m., the Director of Nursing (DON) confirmed that Resident R1' s care plan did not specify how often to empty the resident' s colostomy or what type of assistance the resident needed with it.

Review of facility documentation, "Concern Form" dated November 5, 2019, revealed that Resident R1 was "treated with physical aggression i.e. pushed during 4:00 a.m. changing."

Continued review of facility documentation revealed that a verbal witness statement was obtained on November 20, 2019, from a nurse aide who provided care to Resident R1 on November 4, 2019. The nurse aide indicated that "When I went to her room to check on her, I noticed that she had a diaper on and usually she does not wear diaper, I ask her why she had it on, then I helped her on the bedpan, but the diaper was already wet. She stayed on the bedpan then I cleaned her up."

During an interview on November 20, 2019, at 2:15 p.m. with the DON who obtained the above statement, the DON could not explain why Resident R1 had been put in a brief when the aide reported that the resident was wearing one. The DON further stated that the nurse aide did not know the resident and that is why a bedpan was used.

Interview on November 20, 2019, at 2:25 p.m., the Therapy Director confirmed that Resident R1 required supervision assistance with toileting and that Resident R1 was capable of using a toilet. The Therapy Director confirmed that Resident R1 did not require the use of a commode or bedpan for toileting.

Further interview at 2:30 p.m., the DON confirmed that Resident R1' s care plan did not include information on how to toilet the resident.

The facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care that meet professional standards of quality care related to toileting.

28 Pa Code 201.29(j) Resident rights
Previously cited 4/6/19

28 Pa Code 211.11(d) Resident care plan
Previously cited 4/6/19

Plan of Correction - To be completed: 01/10/2020

1.Resident R-1 Care plan updated to reflect colostomy care as well as transfer status.
2. Resident care plans reviewed to assure residents with special needs, I.E. colostomy, Foley, etc,and transfer statuses are updated to reflect necessary care and treatment.
3. Employees in-serviced on incontinence vs continence, the need for incontinence products,dignity, as well as resident transfers and the importance of looking at kardex.
4. Care plan Audits will be completed weekly by DON and/or designee and submitted to Nursing Home Administrator to be reviewed monthly as part of Quality Assurance Performance Improvement Program.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the failed to maintain complete and accurate clinical records related to colostomy care for one of three residents reviewed (Resident R1).

Findings include:

Review of facility policy, "Colostomy (a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall) /Ileostomy Care" dated revised February 2019, revealed that "The following information should be recorded in the resident' s medical record: The date and time the colostomy/ileostomy care was provided, the name and title of the individual(s) who provided the colostomy/ileostomy care, any breaks in the resident' s skin ... how the resident tolerated the procedure ... the signature and title of the person recording the data."

Interview on November 20, 2019, at 9:10 a.m., Resident R1 stated that she sometimes has to wait too long for assistance to go to the bathroom and that staff only empty her colostomy when she asks. The resident further indicated that staff do not empty her colostomy every shift, that it gets full frequently, leaks, comes off, spills stool on her and that she needs assistance with emptying it.

Review of Resident R1' s Medication Administration Records (MARs) for November 2019 revealed a physician' s order dated October 30, 2019, for "Colostomy care every shift and as needed." Continued review of the MARs revealed that no colostomy care was recorded as provided on seven shifts; specifically, that no care was documented on November 1, 5, 6 and 19 on the day shift, November 7 on the evening shift and November 2 and 14 on the night shift.

Review of Resident R1' s progress notes revealed that no notes were available on the above dates to indicate if colostomy care was provided.

Review of nurse aide documentation related to bowel management revealed that no bowel management information was recorded on 16 shifts; specifically that no information was recorded for any shift on November 1, and that no information was recorded on November 2, 5, 6, and 18 on the day shift, November 5, 11, 13 and 17 on the evening shift and November 2, 3, 6, 7 and 18 on the night shift.

Interview on November 20, 2019, at 1:20 p.m. the Director of Nursing (DON) confirmed that Resident R1' s colostomy care was not documented on the above dates.

The failed to maintain complete and accurate clinical records related to colostomy care.

28 Pa Code 211.5(f) Clinical records
Previously cited 4/6/19

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 4/6/19

Plan of Correction - To be completed: 01/10/2020

1. Individual Nurse/s for specific days noted in-serviced on documentation; R-1 not affected by deficient practice.
2. MARS?TARS reviewed for residents to assure completion; No Other residents affected by deficient practice
3. DON in-serviced on checking clinical dashboard daily; In-service for License Nurses on completion of documentation during the time treatment and/or care is given.
4. Audits will be completed daily by DON and submitted weekly and submitted to Nursing Home Administrator to be reviewed monthly as part of the Quality Assurance Performance Improvement Program.

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