Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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 complaint survey in response to five complaints completed on October 2, 2019, it was determined The Gardens at West Shore was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

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 clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure each resident's right to be free from neglect for one of seven residents reviewed (Resident 6).

Findings Include:

Review of the facility policy titled, Abuse Reporting and Investigation most recently reviewed in June 2019, describes neglect as "Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."

Review of Resident 6's clinical record revealed diagnoses that included Dementia (an irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness and chronic gout ( a form of arthritis characterized by severe pain, redness and tenderness in joints),

Review of Resident 6's Admission Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated February 28, 2019, revealed under toilet use that Resident 6 was coded as requiring extensive assistance with two plus persons physical assist. Extensive assistance is described as "resident involved activity; staff provide weight-bearing support."

Review of Resident 6's care plan, initiated on August 28, 2019, states that Resident 6 has a focus area for urine incontinence and interventions are listed as assist to toilet as needed, provide incontinence care as needed. Additionally, he has a care focus area for self care and an intervention includes that Resident 6 is totally dependent on staff for toilet use.

Review of a facility provided report dated September 3, 2019, revealed the following staff description of an incident: Spouse of Resident 6 alleged that she came in to visit on September 1, 2019, and found him to have been incontinent of urine and needed care.

Further review of the report revealed a statement submitted by the Director of Nursing (DON) that states when Resident 6's spouse came to visit him on September 1, 2019, at noon, he was soaked in urine, his pants were wet and it appeared that there was dried urine under his wheelchair as the floor was sticky. Investigation by the facility resulted in no documentation being found for dayshift hours on September 1, 2019, or an assignment sheet for who was assigned to Resident 6. The DON's statement further states that Nurse Aide (NA) 1 was interviewed by the DON and that NA 1 stated she left at 11 AM on September 1, 2019, due to illness and that she did not provide care to Resident 6 during the time she was there (from 7 Am until 11 AM), despite her statement that she had been assigned to the part of the hall which would have included his room. In another statement attached to the facility investigation of the allegation, the DON wrote "he was in the dining room all night. He was restless and we were keeping him under supervision. I did not see any of the CNAs bring him out of the lounge to provide care and I cannot tell you who was assigned to him". A statement provided to the DON by NA 2 regarding the September 1, 2019 allegations reads that NA 2 came in at 11 AM (on September 1, 2019), started to work when Resident 6 was brought to her to be cleaned up. Her statement says that Resident 6 was put into bed and NA 2 had to strip his bed because he was so wet and the sheets got wet from him, had to clean and dry his wheelchair.

An interview with the Nursing Home Adminstrator on October 2, 2019, at 2:45 PM provided no additional information to explain why the resident was found soaked in urine

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

28 Pa. Code 211.11(d) Resident care plan.

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

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

Plan of Correction - To be completed: 11/05/2019

Resident #6 did not have a negative outcome related to the September 1, 2019 incident. Facility was unable to validate the Responsible Parties subjective statements regarding his incontinence and sticky substance on the floor. Resident #6 no longer resides in the facility. Facility was unable to substantiate abuse or neglect as a result of its investigation.
Facility grievances will be audited for previous 14 days. Follow-up investigations will be completed as necessary based on findings.
Education on facility's Abuse\neglect policy will be completed with facility staff.
Weekly audits of facility grievances abuse/neglect investigations will be conducted weekly for three months by the Nursing Home Administrator or designee. Results of audits will be submitted to the Quality Assurance Committee monthly for further action planning as needed and determination for continuation of audits.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

�483.21(b) Comprehensive Care Plans
�483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on facility policy and clinical record review and interviews with staff, it was determined that the facility failed to review and revise the residents's care plan to meet the physical and mental conditions of each resident for one of seven residents reviewed (Resident 5)

Findings included:

Review of the facility's policy, "Care Plans, Comprehensive Person-Centered," last reviewed in June 2019, revealed that a comprehensive. person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team must review and update the care plan when the resident has been readmitted to the facility from a hospital stay.

Review of Resident 5's clinical record revealed diagnoses that included Unspecified Dementia with Behavioral Disturbances (irreversible progressive degeneration disease of the brain), difficulty walking and a history of falling.

Review of Resident 5's comprehensive care plan dated July 13, 2019, revealed a focus area related to risk for elopement and that interventions for this included to redirect the resident from exits (initiated September 6, 2019) and to check on him every 15 (initiated September 12, 2019).

Review of a facility event dated September 6, 2019, revealed that Resident 5 had been observed propelling himself outside of the facility stating he wanted to go home. Review of nursing progress note dated September 22, 2019, at 22:54 revealed that a nurse aide found the window in resident 5's room to be broken, when it happened is unknown and no alarm sounded. Registered Nurse (RN) did an assessment and placed the resident on one-to-one for safety. A second nursing progress noted dated September 22, 2019, at 22:02 states that a RN assessed the resident related to the broken glass found in the room and found no new bruising or cuts on his skin. Review of Resident 5's most recent care plan revealed no one-to-one intervention added related to Resident 5's risk for elopement.

Additionally, Resident 5's care plan revealed a focus area related to falls, dated July 8, 2019. Review of facility fall reports for Resident 5 revealed he had falls on the following dates:
August 22, 2019, found on knees attempting to get out of bed, no injures, bed alarm added to care plan;
September 2, 2019, found on floor at side of bed, no injuries, new pad alarm added;
September 9, 2019, found on floor, no injuries, provide with increase in religious activities when restless
September 14, 2019, fell out of wheelchair, sent to hospital for hypoglycemic and unresponsive episode. Resident was admitted to hospital with diagnosis of pneumonia (an lung infection)and sepsis (an infection in the blood stream). Nursing progress notes revealed that resident 5 was admitted to the hospital on September 14, 2019, until his return to the facility on September 19, 2019. Review of Resident 5's care plan revealed none were developed for pneumonia or sepsis.

During an interview with Administrator and Director of Nursing on October 2, 2019, at 2:45 PM confirmed that Resident 5's care plan should have been updated to reflect new interventions for risk of elopement and diagnoses of pneumonia and sepsis.

28 Pa. Code 211.11(d) Resident care plans

Plan of Correction - To be completed: 11/05/2019

Resident #5's care plan has been updated to reflect his current condition.
The past 14 days of orders will be audited to ensure Facility care plans have been updated to reflect current condition .
Education on facility's care planning policy will be completed with Licensed staff.
Audits of 10 random Facility care plans will be completed weekly for 3 months.
Results of audits will be submitted to the Quality Assurance Committee monthly for further action planning as needed and determination for continuation of audits.

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