Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT WEST SHORE, THE
Patient Care Inspection Results

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GARDENS AT WEST SHORE, THE
Inspection Results For:

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GARDENS AT WEST SHORE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on February 3, 2020, in response to two complaints, it was determined that Gardens at West Shore 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:


483.25(l) REQUIREMENT Dialysis:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received dialysis for one of three hemodialysis residents reviewed (Resident 2), resulting in harm to Resident 2 who was admitted to the hospital with cardiopulmonary arrest, hyperkalemia and requiring emergent dialysis.

Findings Include:

Review of Resident 2's clinical record revealed diagnoses that included congestive heart failure (CHF-a chronic condition in which the heart doesn't pump blood as well as it should) and end stage renal disease (ESRD-failure of kidney function to remove toxins from blood). Review of Resident 2's physician order, with an order date of January 2, 2020 and a start date of January 3, 2020, revealed that he is to receive dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) on Mondays, Wednesdays, and Fridays.

Further review of Resident 2's clinical record revealed that he was admitted to the hospital on Saturday, December 28, 2019, and was readmitted to the facility on Thursday, January 2, 2020. Hospital documentation indicated that the resident was discharged from the hospital at 8:12 PM on January 2, 2020. A nursing progress note dated January 2, 2020 at 9:03 PM documented an assessment by an RN upon the resident's return which noted the presence of a dialysis port. Review of Resident 2's physician history and physical, dated January 3, 2020, at 10:24 AM revealed under "Plan" to continue with the dialysis Monday, Wednesday, and Friday per nephrology. Review of Resident 2's clinical record on January 13, 2020, at approximately 9:30 AM revealed no evidence that Resident 2 went to dialysis on Friday, January 3, 2020.

Review of Resident 2's nursing progress note dated January 5, 2020, at 10:45 PM revealed that at approximately 10:25 PM, Resident 2 was complaining of shortness of breath and his oxygen saturation (amount of oxygen in the blood) was in the "50's" (normal is 90-100%). Resident 2 was transferred to the hospital at 10:40 PM.

Review of Resident 2's physician history and physical examination from the hospital, dated January 6, 2020, at 12:24 AM revealed that Resident 2 "was supposed to have dialysis on Friday [January 3] but the nursing home failed to make his transportation arrangements." Upon arriving to the hospital, Resident 2 "suffered a cardiopulmonary arrest" (a sudden loss of blood flow resulting from the failure of the heart to pump effectively) requiring CPR (an emergency procedure consisting of mouth-to-mouth respiration and chest compressions). Resident 2's initial potassium level was 6.6 (normal is 3.5-5.1). Further review of the history and physical revealed that Resident 2 was admitted to the ICU (intensive care unit) with diagnoses of status post cardiopulmonary arrest, hyperkalemia (increased potassium), and end-stage renal disease, and that Resident 2 required emergent dialysis for the hyperkalemia.

During an interview with the Director of Nursing (DON) on January 13, 2020, at 11:00 AM she confirmed that Resident 2 did not go to dialysis on Friday, January 3, 2020. She stated that Resident 2 was readmitted to the facility late on January 2, 2020, and the transportation service that regularly transports Resident 2 to dialysis was booked on January 3, 2020 and was unable to take him to dialysis. Resident 2 requires to be transported via stretcher.

During an additional interview with the DON at 11:20 AM she stated that Resident 2 was discharged from the hospital on January 2, 2020, at 8:12 PM and there was no communication from the hospital to the facility that Resident 2 was coming back to the facility.

During an interview with the Unit Manager, Registered Nurse (RN) 1 on January 13, 2020, at 11:45 AM she stated that she was unaware that Resident 2 was coming back to the facility on January 2, 2020. She stated when she got to the facility on Friday, January 3, 2020, she contacted the facility's transport company who contacted the transport company who transports Resident 2 to dialysis. She stated that Resident 2's transport company was booked and was unable to transport Resident 2. She also stated that his dialysis center didn't know he was back in the facility and they were unsure if they could accommodate him. RN 1 stated that Resident 2's dialysis center is not open on Saturdays or Sundays.

Review of Resident 2's late entry progress note, with an effective date of January 3, 2020, at 10:35 AM but a created date of January 13, 2020, at 11:23 AM revealed that Resident 2 returned back to the facility at approximately 9:00 PM the previous night. Resident 2's normal schedule for dialysis is to be Monday, Wednesday, and Friday and no transportation is available due to resident's late arrival the night before. Dialysis unable to fit resident in at a different time.

On January 24, 2020, at 1:20 PM during an interview with the supervisor at the dialysis center that Resident 2 goes to, she stated that Resident 2 had his normal dialysis time available on January 3, 2020. She stated that a patient's dialysis spot is available up to 30 days. If a patient is out for greater than 30 days, which Resident 2 was not, then that patient would have to be readmitted. She stated that the dialysis center called the facility on January 3, 2020, asking where Resident 2 was, and the facility told the dialysis center they did not have transportation to send Resident 2 to dialysis. She stated that the dialysis center can't make the facility bring the patient, but they told the facility that Resident 2 needs dialysis and if the facility wasn't going to transport him to his scheduled dialysis treatment, then the facility needed to closely monitor the resident. Review of Resident 2's clinical record failed to reveal that Resident 2 was closely monitored as instructed by the dialysis nurse.

During an interview with the Nursing Home Administrator, on January 13, 2020, at 3:00 PM she stated that if Resident 2 could be transported by wheelchair the facility staff could have taken him to dialysis, but since he requires to be transported via stretcher, the facility couldn't get transportation for him because the hospital never let the facility know that he was coming back. Unit Manager, Registered Nurse (RN) 1, stated during the same interview, in the presence of the DON, that if the facility had a concern with Resident 2 not receiving dialysis, they could have called 911 and transported the resident to the hospital for emergency dialysis.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/30/19, 8/5/19, 4/12/19, 1/23/19, 10/29/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 10/30/19, 7/24/19, 6/20/19, 4/12/19, 3/8/19, 1/23/19, 10/29/18.

28 Pa. Code 201.18(b)(3) Management.
Previously cited 10/30/19, 8/5/19, 4/12/19, 1/23/19, 10/29/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/30/19, 7/24/19, 4/12/19, 1/23/19, 10/29/18.

28 Pa. Code 201.29(c) Resident rights.

28 Pa. Code 201.29(d) Resident rights.
Previously cited 10/30/19, 10/29/18.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 10/30/19, 8/5/19, 4/12/19, 3/8/19, 1/23/19, 10/29/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 10/30/19, 10/16/19, 10/2/19, 7/24/19, 7/10/19, 4/12/19, 3/8/19, 1/23/19, 1/3/19, 10/29/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 10/30/19, 10/2/19, 7/24/19, 7/10/19, 6/20/19, 4/12/19, 3/8/19, 1/23/19, 10/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/19, 10/16/19, 10/2/19, 7/24/19, 7/10/19, 6/20/19, 4/12/19, 3/8/19, 1/23/19, 1/3/19, 10/29/18.
















 Plan of Correction - To be completed: 02/18/2020

Resident 2 no longer resides at the facility
Residents being admitted from the hospital that require outpatient hemodialysis after admission to the facility have the potential to be affected by this alleged deficient practice. The residents will receive their hemodialysis as per MD orders. If transportation services are unavailable or become unavailable, Residents Physician will be notified and consulted for further instructions/orders.
House wide audit of Residents ordered to receive hemodialysis services was completed to ensure they all have transportation scheduled to coordinate with their outpatient hemodialysis schedule.
Licensed staff will be inserviced on ensuring that residents that are admitted from the hospital and require outpatient hemodialysis after admission to the facility have transportation scheduled to coordinate with their outpatient hemodialysis schedule.
Random weekly audits will be conducted to ensure that residents being admitted from the hospital that require outpatient hemodialysis after admission to the facility have transportation scheduled to coordinate with their outpatient hemodialysis schedule. These audits will be completed weekly x 4 and then monthly x 2 or until substantial compliance has been achieved. Results and findings will be reported monthly at QAPI for 3 months for further review and recommendations as needed.

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