Nursing Investigation Results -

Pennsylvania Department of Health
TIMBER RIDGE HEALTH CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TIMBER RIDGE HEALTH CENTER
Inspection Results For:

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TIMBER RIDGE HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on December 12, 2019, at Timber Ridge Health Center deficient facility practice was identified and cited as past non-compliance under the 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 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 clinical records, select investigative reports and the facility's abuse prohibition policy and interview with staff it was determined that the facility neglected to provide a resident with necessary care to avoid physical harm, pain and discomfort for one out of 15 residents reviewed (Resident 131)

Findings include:

The facility's "Resident Abuse and Neglect Prevention Program" dated as reviewed by the facility June 2019, stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility defines abuse as actions such as willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to avoid physical harm, mental anguish, or emotional distress.

A review of the clinical record revealed that Resident 131 was admitted to the facility on February 23, 2018, with diagnoses to include dementia (general term for a decline in mental ability severe enough to interfere with daily life) and abnormality of gait.

A significant change Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 9, 2019, revealed that the resident was severely cognitively impaired, required maximum assistance of staff for activities of daily living including bed mobility, transfers and walking.

A review of nursing documentation dated November 29, 2019, at 4:00 PM revealed that staff called Employee 1, RN (registered nurse), to the floor to assess Resident 131. The resident was complaining of feeling like she had "a rock under her buttocks" and complained of pain in her buttocks. The resident was found to have a reddened area on her buttocks in the shape and size of a bed pan. The resident's left buttock had an 8 cm (centimeter) x 3 cm DTI (deep tissue injury: a pressure-related injury to subcutaneous tissues \ under intact skin. Initially, these lesions have the appearance of a deep bruise) with a 2.5 cm x 1cm fluid filled blister. The resident's right buttock had a 2 cm x 1 cm DTI. It was also noted that the resident had an unstageable pressure sore (severity cannot be determined with a visual exam) on her coccyx (area at the base of the spinal column) that measured 2.5 cm x 2 cm x 0. 2cm with a large amount of thick tan drainage and was had a black color in the center of the wound.

A review of the facility investigation report dated November 29, 2019, at 8:44 PM revealed that Employees 2, Nurse Aide and 3, LPN (licensed practical nurse) had placed Resident 131 on the bed pan at 6:00 AM on November 29, 2019. At approximately 1:00 PM, Employee 4, nurse aide removed the resident from the bed pan. At that time the resident was found to have reddened areas and a blister on her buttocks.

A review of Employee 2's statement regarding the incident dated November 29, 2019, indicated that Employee 2 was helping Employee 3 give Resident 131 an enema. Employee 2 stated they finished up and put the resident on the bed pan. Employee 2 further stated she gave Employee 5, nurse aide, a report of the night and informed Employee 5 that Resident 131 was on the bed pan due to the resident just receiving an enema and she should be done soon. Employee 2 stated that Employee 5 acknowledged her by stating "okay."

A review of Employee 4's statement regarding the incident dated November 29, 2019, indicated she was called in to the resident's room by Resident 131's roommate. The resident's roommate informed Employee 4 that Resident 131 was complaining of pain in her bottom. Resident 131's roommate also told Employee 4 that the resident had been on the bed pan since early in the morning. Employee 4 stated that she took the resident off the bed pan, cleaned her up and notified the charge nurse.

A review of Employee 5's statement regarding the incident dated November 29, 2019, revealed that the employee changed the resident around 7:18 AM and stated that she wasn't on the bed pan on that time. The employee asked the resident at 10:20 AM if she went to the bathroom yet and the resident responded no. The employee further stated that staff yelled to her to ask when she put the resident on the bed pan. Employee 5 stated she did not put her on the bed pan. The employee stated that she changed the resident again around 1:30 PM and didn't see any red marks on her bottom. Employee 5's statement was not consistent with the resident's roommate's or Employee 4's statement.

Further review of the facility incident report reveled no documented statement from Employee 3.

A review of information December 3, 2019, submitted by the facility revealed Resident 131 was on Employee 5's assignment on the day tour of duty on November 29, 2019. The facility concluded that Employee 5 did not render morning care to the resident as evidenced by the condition of the resident's bed, which contained urine and feces. The facility suspended Employee 5 and substantiated the allegation against the employee. The employee resigned from her position.

During an interview December 12, 2019 at approximately 2:30 PM the Director of Nursing (DON) confirmed Employee 5 did not provide timely and necessary care to Resident 131, which resulted in the resident remaining on the bedpan and soiled bedding for an extended period of time and sustaining skin damage.

This deficiency is cited as past non-compliance.

The facility's corrective action plan was to suspend the nurse aide responsible for the resident. The resident was assessed by the registered nurse and the treatment was changed to her coccyx. The resident has new interventions to turn and reposition every hour and air mattress to be placed on the bed. Registered nurse will assess every shift the status of the resident's wounds and notify the physician of any changes. Staff scheduled for duty at the time of the occurrence were in serviced by registered nurse supervisor related to abuse and neglect policy and procedure, bed pan procedure, and report process. The resident group, to which Employee 5 was assigned for her shift, were audited for care by registered nurse supervisor to identify if any other residents in the employee's care were affected. Current facility nursing staff will be in serviced prior to their next schedule shift relating to abuse and neglect policy, bed pan procedure, and reporting procedure. Random care audits will be completed by license staff daily for two weeks, weekly for four weeks, then monthly for 1 month with results given to quality assurance and performance improvement. The facility's compliance date was December 4, 2019.




28 Pa. Code 201.18(e)(1) Management
Previously Cited 7/26/19, 10/30/19

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

28 Pa. Code 201.29(a)(c) Resident Rights
Previously Cited 7/26/19

28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services
Previously Cited 7/26/19, 9/10/19, 10/30/19



 Plan of Correction - To be completed: 12/20/2019

Past noncompliance: no plan of correction required.

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