Nursing Investigation Results -

Pennsylvania Department of Health
TULIP SPECIAL CARE, LLC
Patient Care Inspection Results

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TULIP SPECIAL CARE, LLC
Inspection Results For:

There are  9 surveys for this facility. Please select a date to view the survey results.

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TULIP SPECIAL CARE, LLC - 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 October 1, 2019, it was determined that Tulip Special Care 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)(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 interviews with facility staff and review of facility documentation, it was determined that the facility failed to report an incident of alleged verbal abuse and an incident of a resident transfer to the hospital due to an accident to the Pennsylvania Department of Health, as required for two of three residents reviewed. (Resident R2 and Resident R1).

Findings include:

Review of facility policy "Incidents and Accidents Document" dated April 01, 2018 revealed that the facility will maintain documentation if incidents and accidents occur. Events that are reportable to regulatory authorities will be communicated promptly per regulation".

Review of facility document "Grievance/Concern Form" dated August 5, 2019, revealed a witness statement by Resident R2 alleging verbal abuse by a staff member. In the statement signed by Resident R2 dated August 5, 2019 alleged that on August 3 night into August 4, 2019 the resident was crying, and the nursing assistant walked in and told the resident to "stop whining". Resident stated, "the aide sticks her face about 2-3 feet away from face and tilts her head and goes "wah wah wah". Resident stated the aide made other comments and the resident never reported them.

Review of the Grievance/Concern Report dated August 5, 2019 revealed section "facility follow up" indicated that the alleged staff was removed from the care for Resident R2 for two weeks and education regarding rude and discourteous comments were given to the staff member.

Interview with the director of nursing on October 1, 2019 at approximately 12 p.m. confirmed that facility did not report the allegation of verbal abuse to Pennsylvania Department of Health as required.

Review of a progress note for Resident R1 dated May 23, 2019 at approximately 5:01 p.m. revealed that resident R1 was found on the floor lying next to the bed. Resident complained of right sided head discomfort. Physician assessed the resident and ordered to send resident to the hospital. Further review of progress note revealed that Resident R1 was transferred to the hospital.

Interview with director of nursing, Employee E2, on October 1, 2019 at approximately 1 p.m. revealed that there was no evidence that the incident of resident transfer to the hospital because of an accident was reported to Pennsylvania Department of Health as required.

The facility failed to report an incident of alleged verbal abuse and an incident of resident transfer to the hospital due to an injury to the Pennsylvania Department of Health as required by federal and state regulation.

201.14. (c) Responsibility of licensee.
Previously Cited: 4/6/19



 Plan of Correction - To be completed: 11/15/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.

It is the goal of the facility to 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.

A 100% review of the Grievance/Concern log took place by Social Service to ensure that a reportable was not missed.

An in service took place to Review the following:

1)- The PA DOH definition of a reportable incident.

2)- The facilities policy and procedure on "Incidents and Accident's.

3)- Review of the facilities "Grievance and Concern" form.

The aforementioned will ensure that the facility reports an incident of alleged verbal abuse and/or an incident of resident transfer to the hospital due to an injury to the Pennsylvania Department of Health as required by federal and state regulation.

The "Grievance Log" is now brought to the daily morning meeting to be reviewed in real time by the interdisciplinary team. Any issues are corrected immediately.

The Grievance Log will be audit by the NHA during the weekly Leadership Meeting.

Results will be brought to the monthly QAPI meeting for review/resolution.







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, clinical records and facility documents and staff interview, it was determined that the facility failed to thoroughly investigate two incidents of resident falls to evaluate for possible staff neglect for one of three residents reviewed. (Resident R1).

Findings include:

Review of facility policy "Incidents and Accidents Document" dated, April 01, 2018 revealed that "The facility will maintain documentation if incidents and accidents occur. Documentation and an investigation will begin immediately. Analysis, preventative plan, summary, determination and follow up will be completed in a timely manner. Care plan will be updated as appropriate. Staff will notify family, attending physician and other departments".

Review of a progress note for Resident R1 dated May 23, 2019 at approximately 5:01 p.m. revealed that Resident R1 was found on the floor lying next to the bed. Resident complained of right sided head discomfort. Physician assessed the resident and ordered to send resident to the hospital. Further review of progress note revealed that Resident R1 was subsequently transferred to the hospital.

Review of facility Incident/Accident report dated May 23, 2019 at approximately 4:25 p.m. revealed an incomplete facility investigation with no documentation entered in sections of "Incident Description" and "Immediate action taken". Further review of the report indicated no documented evidence that staff assessed predisposing environmental, physiological and situational factors prior to the fall.

Review of clinical record for Resident R1 revealed a nursing progress note dated September 13, 2019 at 10:09 a.m. revealed that "Patient found sitting on the floor in his room next to bed. He was awake and alert with baseline mentation. Incontinence brief with soft stool, in which total care was rendered by the CNA".

Review of facility incident/Accident Reports for Resident R1 revealed no evidence that an incident/accident report was completed for the resident's fall on September 13, 2019.

Interview with director of nursing on October 1, 2019 at approximately 1:00 p.m. confirmed that the facility did not complete a thorough incident/accident investigation for Resident R1's fall on September 13, 2019.

The facility failed to thoroughly investigate and evaluate for possible staff neglect related to two incidents of falls for one of three residents reviewed.


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

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

28 Pa. Code 211.10(d) Resident care policies.
Previously cited 4/6/19

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
Previously cited 9/5/19, 4/6/19





 Plan of Correction - To be completed: 11/15/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.

It is the goal of the facility that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will have evidence that all alleged violations are thoroughly investigated. In addition to ensure the prevention of further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 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.

A 100% review of the facilities "incident/Accident" reports for the last 6 months took place by the Director of Nursing.

An in service took place on completing the "Incident/Accident form and how to conduct a through investigation.

All incidents/accidents are now being brought to the daily morning meeting to receive interdisciplinary input to the resolution.

The "Incident/Accident log will be audited weekly by the Director of Nursing.

The results of the audit will be brought to the monthly QAPI meeting for review/resolution.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(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 clinical records, it was determined that the facility failed to maintain complete and accurate clinical records related to wound care administrations for one of three records reviewed (Resident R3).

Findings include:

Review of the clinical record for Resident R3 revealed that the resident had been admitted to the facility on November 21, 2018, with diagnosis including but not limited to, acute and chronic respiratory failure and neuromuscular dysfunction of the bladder.

Review of physician orders dated July 15, 2019, revealed an order "cleanse left ischium (upper posterior aspect of hip bone) with wound cleanser, apply calcium alginate (a highly absorbent wound care product which promote wound healing) and cover with dry dressing every day shift". Review of Treatment Administration Record (TAR) for August 2019 revealed no evidence that staff documented the wound care administration in the treatment administration record on August 4, 5, 22, 26 and 27, 2019, as ordered by the physician.

Review of the physician order dated August 21, 2019 revealed an order "cleanse left outer hip wound with wound cleanser, pat dry. Apply calcium alginate to wound base, cover with dry dressing every day shift for wound care." Review of Treatment Administration Record (TAR) for August 2019 and September 2019 revealed no evidence that staff documented the wound care administration in the TAR on August 26 and 27, 2019 and September 5, 2019, as ordered by the physician.

Review of the physician order dated August 21, 2019 revealed an order to" Cleanse right ischium with wound cleanser, apply calcium alginate and cover with dry dressing every day shift." Review of Treatment Administration Record (TAR) for August 2019 and September 2019 revealed no evidence that staff documented the wound care administration in the TAR on August 26, 27, 29, 2019 and September 5, 2019, as ordered by the physician.

Review of physician orders dated September 10, 2019, revealed an order "cleanse left ischium with wound cleanser, apply calcium alginate and cover with dry dressing every night shift". Review of Treatment Administration Record (TAR) for the month of September 2019 revealed no evidence that staff documented the wound care administration in the TAR on September 23, and 27, 2019, as ordered by the physician.

Review of physician orders dated September 10, 2019, revealed an order "cleanse right ischium with wound cleanser, apply calcium alginate and cover with dry dressing every night shift." Review of Treatment Administration Record (TAR) for the month of September 2019 revealed no evidence that staff documented the wound care administration in the TAR on September 23 and 27, 2019 as ordered by the physician

Facility did not maintain complete and accurate clinical records related to wound care administrations for one resident.



28 Pa Code: 211.5(f) Clinical records.
Previously Cited 4/6/19

28 Pa Code: 211.12(d)(1) Nursing services.
Previously cited 9/5/19. 4/6/19







 Plan of Correction - To be completed: 11/15/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State Law.

It is the goal of the facility to maintain complete and accurate clinical records related to wound care administrations.

A 100% review of the of the Treatment Administration Record(TAR) took place by nursing.

An in-service took place attended by the professional nurses on the proper completion of the Treatment Administration Record(TAR)

This will be audited by the Nurse Manager and/or DON and findings reported to the QAPI committee.This will be monitored by the DON.


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